- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.59 / $55.00 / $55.00
| Facility | | $16.59 | $55.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.59 / $16.59 / $16.59
| Professional | | $16.59 | $16.59 | $16.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.37 / $50.38 / $128.13
| Facility | | $24.37 | $50.38 | $128.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.59 / $18.25 / $22.40
| Facility | | $16.59 | $18.25 | $22.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $13.35
| Professional | | $10.68 | $10.68 | $13.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.38 / $34.08 / $37.24
| Professional | | $32.38 | $34.08 | $37.24 |