- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.35 / $47.23 / $243.50
| Facility | | $11.35 | $47.23 | $243.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $14.13
| Professional | | $11.36 | $11.36 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.00 / $42.00 / $42.00
| Professional | | $42.00 | $42.00 | $42.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $11.36
| Facility | | $11.36 | $11.36 | $11.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $11.36
| Professional | | $11.36 | $11.36 | $11.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $100.00 / $100.00
| Facility | | $75.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $32.92
| Professional | | $11.36 | $11.36 | $32.92 |