- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.88 / $92.35 / $296.88
| Facility | | $23.88 | $92.35 | $296.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $23.88 / $26.26
| Professional | | $23.88 | $23.88 | $26.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $29.60 / $35.46
| Professional | | $23.88 | $29.60 | $35.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.53 / $22.53 / $23.88
| Facility | | $22.53 | $22.53 | $23.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $23.88 / $30.41
| Professional | | $23.88 | $23.88 | $30.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $23.88 / $72.43
| Professional | | $20.30 | $23.88 | $72.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $26.58 / $35.15
| Professional | | $23.88 | $26.58 | $35.15 |