- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.42 / $10.42 / $10.42
| Facility | | $10.42 | $10.42 | $10.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.42 / $22.84 / $109.86
| Professional | | $10.42 | $22.84 | $109.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.44 / $19.44 / $19.44
| Professional | | $19.44 | $19.44 | $19.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.01 / $30.98 / $44.08
| Professional | | $25.01 | $30.98 | $44.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.18 / $26.65 / $26.65
| Professional | | $21.18 | $26.65 | $26.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.64 / $16.14 / $24.32
| Professional | | $12.64 | $16.14 | $24.32 |