- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.82 / $108.81 / $131.01
| Professional | | $90.82 | $108.81 | $131.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $26.00 / $33.00
| Professional | | $7.00 | $26.00 | $33.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.60 / $17.60 / $33.20
| Professional | | $17.60 | $17.60 | $33.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $90.00 / $100.00
| Facility | | $70.00 | $90.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.16 / $152.16 / $152.16
| Professional | | $152.16 | $152.16 | $152.16 |