- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.77 / $15.77 / $19.14
| Facility | | $15.77 | $15.77 | $19.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.95 / $15.77 / $33.61
| Professional | | $11.95 | $15.77 | $33.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.35 / $33.35 / $37.57
| Professional | | $28.35 | $33.35 | $37.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.58 / $26.58 / $26.58
| Professional | | $26.58 | $26.58 | $26.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |