- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.10 / $34.85 / $34.85
| Professional | | $27.10 | $34.85 | $34.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $145.13
| Facility | | $75.00 | $75.00 | $145.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $22.55 / $34.50
| Professional | | $22.55 | $22.55 | $34.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.10 / $54.17 / $54.94
| Facility | | $45.10 | $54.17 | $54.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.44 / $35.26 / $42.21
| Professional | | $34.44 | $35.26 | $42.21 |