- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.32 / $14.32 / $14.32
| Facility | | $14.32 | $14.32 | $14.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.32 / $23.87 / $32.34
| Professional | | $14.32 | $23.87 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $34.47 / $39.95
| Professional | | $19.95 | $34.47 | $39.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.67 / $18.18 / $33.78
| Professional | | $2.67 | $18.18 | $33.78 |