- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $26.92 / $64.57
| Professional | | $19.95 | $26.92 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $40.74 / $72.44
| Professional | | $29.51 | $40.74 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $22.39 / $30.20
| Professional | | $16.22 | $22.39 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $44.67
| Professional | | $34.67 | $34.67 | $44.67 |