- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.00 / $42.00 / $42.00
| Facility | | $42.00 | $42.00 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.43 / $32.65 / $50.40
| Professional | | $22.43 | $32.65 | $50.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.31 / $138.31 / $138.31
| Facility | | $138.31 | $138.31 | $138.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.62 / $40.53 / $51.73
| Professional | | $30.62 | $40.53 | $51.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.00 / $41.00 / $70.70
| Professional | | $26.00 | $41.00 | $70.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $40.00 / $60.70
| Professional | | $29.36 | $40.00 | $60.70 |