- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.48 / $28.32 / $48.69
| Professional | | $19.48 | $28.32 | $48.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $90.00
| Facility | | $30.00 | $30.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $43.00 / $491.00
| Professional | | $17.38 | $43.00 | $491.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.82 / $30.00 / $30.00
| Facility | | $18.82 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.25 / $29.22 / $40.49
| Professional | | $17.25 | $29.22 | $40.49 |