- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.87 / $157.18 / $314.36
| Facility | | $29.87 | $157.18 | $314.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.52 / $43.20 / $48.60
| Professional | | $29.52 | $43.20 | $48.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.51 / $57.51 / $57.51
| Professional | | $57.51 | $57.51 | $57.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.60 / $30.60 / $30.60
| Facility | | $30.60 | $30.60 | $30.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.60 / $30.60 / $36.00
| Professional | | $30.60 | $30.60 | $36.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.80 / $30.00 / $39.00
| Professional | | $28.80 | $30.00 | $39.00 |