- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $120.06
| Facility | | $120.06 | $120.06 | $120.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.60 / $22.30 / $37.22
| Professional | | $15.60 | $22.30 | $37.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.02 / $31.38 / $31.38
| Professional | | $24.02 | $31.38 | $31.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.55 / $52.07 / $103.95
| Professional | | $30.55 | $52.07 | $103.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.45 / $30.62 / $66.31
| Professional | | $22.45 | $30.62 | $66.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |