- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $21.00 / $26.25
| Professional | | $21.00 | $21.00 | $26.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.27 / $32.27 / $32.27
| Professional | | $32.27 | $32.27 | $32.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.27 / $32.27 / $32.27
| Professional | | $32.27 | $32.27 | $32.27 |