- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.21 / $140.94 / $140.94
| Professional | | $25.21 | $140.94 | $140.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.78 / $37.26 / $124.94
| Facility | | $31.78 | $37.26 | $124.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $31.78 / $31.78
| Professional | | $13.78 | $31.78 | $31.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.78 / $37.26 / $124.94
| Facility | | $31.78 | $37.26 | $124.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.73 / $19.73 / $31.78
| Professional | | $19.73 | $19.73 | $31.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.21 / $9.21 / $28.02
| Professional | | $9.21 | $9.21 | $28.02 |