- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.75 / $50.27 / $62.83
| Professional | | $39.75 | $50.27 | $62.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.88 / $33.61 / $139.00
| Facility | | $30.88 | $33.61 | $139.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.56 / $44.00 / $50.00
| Professional | | $24.56 | $44.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.56 / $24.56 / $50.00
| Facility | | $24.56 | $24.56 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.33 / $44.00 / $50.00
| Professional | | $30.33 | $44.00 | $50.00 |