- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.52 / $191.52 / $191.52
| Facility | | $191.52 | $191.52 | $191.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.81 / $147.47 / $213.63
| Facility | | $109.81 | $147.47 | $213.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.61 / $12.62 / $42.68
| Facility | | $9.61 | $12.62 | $42.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.80 / $57.55 / $85.00
| Facility | | $10.80 | $57.55 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |