- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.72 / $38.72 / $38.72
| Facility | | $38.72 | $38.72 | $38.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $38.72 / $38.72
| Professional | | $37.04 | $38.72 | $38.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.21 / $72.58 / $104.20
| Facility | | $58.21 | $72.58 | $104.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.43 / $48.26 / $48.26
| Professional | | $43.43 | $48.26 | $48.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.27 / $47.60 / $71.81
| Professional | | $39.27 | $47.60 | $71.81 |