- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.02 / $101.02 / $101.02
| Facility | | $101.02 | $101.02 | $101.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.11 / $101.02 / $111.39
| Professional | | $37.11 | $101.02 | $111.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.40 / $83.40 / $83.40
| Professional | | $83.40 | $83.40 | $83.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.54 / $106.86 / $133.63
| Professional | | $46.54 | $106.86 | $133.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.24 / $113.96 / $182.80
| Professional | | $86.24 | $113.96 | $182.80 |