- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $21.00 / $21.00
| Professional | | $21.00 | $21.00 | $21.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.83 / $15.67 / $31.09
| Facility | | $10.83 | $15.67 | $31.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.42 / $4.03 / $17.59
| Professional | | $3.42 | $4.03 | $17.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.38 / $90.00 / $109.64
| Facility | | $75.38 | $90.00 | $109.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $25.34 / $27.73
| Professional | | $21.48 | $25.34 | $27.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.09 / $30.09 / $32.02
| Professional | | $30.09 | $30.09 | $32.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.46 / $5.46 / $5.46
| Facility | | $5.46 | $5.46 | $5.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.13 / $19.38 / $48.84
| Professional | | $11.13 | $19.38 | $48.84 |