- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.48 / $38.96 / $48.69
| Professional | | $19.48 | $38.96 | $48.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $1,300.00
| Facility | | $90.00 | $90.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.00 / $491.00 / $491.00
| Professional | | $43.00 | $491.00 | $491.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.82 / $18.82 / $30.00
| Facility | | $18.82 | $18.82 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.82 / $30.00 / $35.84
| Professional | | $18.82 | $30.00 | $35.84 |