- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.05 / $260.73 / $292.66
| Facility | | $0.05 | $260.73 | $292.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.05 / $0.05 / $0.05
| Professional | | $0.05 | $0.05 | $0.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.69 / $34.69 / $43.37
| Professional | | $34.69 | $34.69 | $43.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.54 / $23.88 / $27.93
| Professional | | $19.54 | $23.88 | $27.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.56 / $10.16 / $14.51
| Professional | | $9.56 | $10.16 | $14.51 |