- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.50 / $19.50 / $128.82
| Facility | | $19.50 | $19.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $14.13 / $51.29
| Professional | | $12.88 | $14.13 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.22 / $11.22 / $11.22
| Facility | | $11.22 | $11.22 | $11.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $19.95 / $31.62
| Professional | | $12.30 | $19.95 | $31.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Facility | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.31 / $10.47 / $25.70
| Professional | | $6.31 | $10.47 | $25.70 |