- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.69 / $325.06 / $758.95
| Facility | | $2.69 | $325.06 | $758.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.69 / $2.69 / $392.46
| Professional | | $2.69 | $2.69 | $392.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.75 / $2.75
| Professional | | $2.75 | $2.75 | $2.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $45.00 / $60.00
| Professional | | $18.44 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.34 / $17.07 / $24.51
| Facility | | $12.34 | $17.07 | $24.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.70 / $2.70 / $2.70
| Professional | | $2.70 | $2.70 | $2.70 |