- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.45 / $36.82 / $45.36
| Professional | | $29.45 | $36.82 | $45.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $39.50 / $76.95
| Facility | | $23.64 | $39.50 | $76.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.00 / $320.00 / $320.00
| Professional | | $320.00 | $320.00 | $320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.00 / $26.00 / $26.00
| Facility | | $26.00 | $26.00 | $26.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.00 / $27.00 / $43.06
| Professional | | $23.00 | $27.00 | $43.06 |