- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.55 / $67.30 / $220.40
| Facility | | $48.55 | $67.30 | $220.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.86 / $100.00 / $100.00
| Professional | | $13.86 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,500.00 / $2,500.00
| Professional | | $2,500.00 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $13.25 / $13.25
| Professional | | $13.25 | $13.25 | $13.25 |