- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.66 / $34.15 / $117.26
| Professional | | $12.66 | $34.15 | $117.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.50 / $136.50 / $150.15
| Facility | | $136.50 | $136.50 | $150.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $130.00 / $130.00
| Professional | | $130.00 | $130.00 | $130.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.07 / $16.28 / $27.82
| Facility | | $6.07 | $16.28 | $27.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $40.00
| Professional | | $17.00 | $20.00 | $40.00 |