- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.50 / $56.00 / $56.00
| Facility | | $46.50 | $56.00 | $56.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $42.00 / $46.50
| Professional | | $40.00 | $42.00 | $46.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.91 / $69.91 / $69.91
| Professional | | $69.91 | $69.91 | $69.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,240.00 / $2,840.00 / $3,375.00
| Facility | | $2,240.00 | $2,840.00 | $3,375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $225.28
| Professional | | $50.00 | $60.00 | $225.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.00 / $73.00
| Professional | | $50.00 | $58.00 | $73.00 |