- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $169.82 / $363.08
| Facility | | $87.10 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.00 / $2.00 / $14.13
| Professional | | $2.00 | $2.00 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.75 / $2.75
| Professional | | $2.75 | $2.75 | $2.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Facility | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.95 / $3.39
| Professional | | $2.75 | $2.95 | $3.39 |