- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $367.50 / $420.00
| Facility | | $40.00 | $367.50 | $420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $41.00 / $354.55
| Professional | | $40.00 | $41.00 | $354.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $42.00
| Facility | | $40.00 | $40.00 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $52.00 / $1,576.96
| Professional | | $47.00 | $52.00 | $1,576.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $50.00 / $62.00
| Professional | | $47.00 | $50.00 | $62.00 |