- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.72 / $25.70 / $380.19
| Facility | | $10.72 | $25.70 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $10.96
| Professional | | $10.00 | $10.00 | $10.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.59 / $15.85 / $23.44
| Facility | | $12.59 | $15.85 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $20.42
| Professional | | $10.72 | $10.72 | $20.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $19.05
| Facility | | $10.72 | $10.72 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $11.75
| Professional | | $10.72 | $10.72 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Facility | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $91.20
| Professional | | $33.88 | $33.88 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.38 / $17.38 / $18.62
| Facility | | $17.38 | $17.38 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $14.13
| Professional | | $10.72 | $10.72 | $14.13 |