- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.63 / $20.63 / $25.78
| Professional | | $20.63 | $20.63 | $25.78 |
- 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
- $31.55 / $31.55 / $31.55
| Professional | | $31.55 | $31.55 | $31.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.55 / $31.55 / $31.55
| Professional | | $31.55 | $31.55 | $31.55 |