- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.11 / $30.11 / $37.64
| Professional | | $30.11 | $30.11 | $37.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $17.00
| Professional | | $17.00 | $17.00 | $17.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.10 / $34.31 / $40.19
| Facility | | $23.10 | $34.31 | $40.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $33.11 / $61.75
| Professional | | $22.55 | $33.11 | $61.75 |