- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.26 / $45.26 / $45.26
| Facility | | $45.26 | $45.26 | $45.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $45.26 / $49.32
| Professional | | $37.04 | $45.26 | $49.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.54 / $242.20 / $352.96
| Facility | | $186.54 | $242.20 | $352.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.67 / $56.32 / $68.65
| Professional | | $40.67 | $56.32 | $68.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.54 / $58.03 / $85.01
| Professional | | $41.54 | $58.03 | $85.01 |