- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.30 / $16.30 / $16.30
| Facility | | $16.30 | $16.30 | $16.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $16.30 / $59.76
| Professional | | $16.30 | $16.30 | $59.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $0.03 / $0.03
| Facility | | $0.03 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.84 / $14.84 / $24.00
| Professional | | $14.84 | $14.84 | $24.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.99 / $13.99 / $13.99
| Facility | | $13.99 | $13.99 | $13.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.99 / $13.99 / $13.99
| Professional | | $13.99 | $13.99 | $13.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.15 / $14.84 / $190.00
| Professional | | $0.15 | $14.84 | $190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $13.38 / $15.12
| Professional | | $13.38 | $13.38 | $15.12 |