- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $72.44 / $74.13
| Facility | | $10.00 | $72.44 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $14.13 / $75.86
| Professional | | $11.22 | $14.13 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $28.84 / $33.88
| Professional | | $21.88 | $28.84 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $17.38 / $21.88
| Professional | | $17.38 | $17.38 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $22.39 / $75.86
| Facility | | $10.47 | $22.39 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $8.91 / $25.70
| Professional | | $4.07 | $8.91 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.07 / $9.55 / $21.88
| Professional | | $4.07 | $9.55 | $21.88 |