- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $12.99
| Facility | | $12.86 | $12.86 | $12.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $14.62
| Professional | | $12.86 | $12.86 | $14.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.03 / $35.92 / $72.14
| Facility | | $15.03 | $35.92 | $72.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $121.37 / $121.37
| Facility | | $80.00 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.13 / $12.86 / $12.86
| Facility | | $12.13 | $12.86 | $12.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $12.86
| Professional | | $12.86 | $12.86 | $12.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $90.00 / $90.00
| Facility | | $75.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.88 / $66.88 / $66.88
| Professional | | $66.88 | $66.88 | $66.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.19 / $14.48 / $19.29
| Facility | | $10.19 | $14.48 | $19.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $16.07
| Professional | | $12.86 | $12.86 | $16.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $15.00 / $205.54
| Professional | | $13.00 | $15.00 | $205.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.32 / $12.86 / $19.48
| Facility | | $10.32 | $12.86 | $19.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $16.30
| Professional | | $12.86 | $12.86 | $16.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $12.86
| Professional | | $12.86 | $12.86 | $12.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $14.48 / $17.36
| Professional | | $12.86 | $14.48 | $17.36 |