- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.40 / $28.40 / $30.60
| Facility | | $28.40 | $28.40 | $30.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.03 / $10.40 / $12.24
| Professional | | $10.03 | $10.40 | $12.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.54 / $31.54 / $31.54
| Facility | | $31.54 | $31.54 | $31.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.19 / $10.40 / $10.40
| Professional | | $10.19 | $10.40 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $85.00
| Facility | | $10.40 | $10.40 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $10.40
| Professional | | $10.40 | $10.40 | $10.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $10.40
| Professional | | $10.40 | $10.40 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.40 / $28.40 / $30.60
| Facility | | $28.40 | $28.40 | $30.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.03 / $10.40 / $12.24
| Professional | | $10.03 | $10.40 | $12.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.19 / $10.19 / $14.79
| Professional | | $10.19 | $10.19 | $14.79 |