- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.34 / $40.32 / $76.31
| Facility | | $34.34 | $40.32 | $76.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.50 / $37.50 / $119.00
| Professional | | $8.50 | $37.50 | $119.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $13.25 / $13.25
| Professional | | $13.25 | $13.25 | $13.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- 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
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |