- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.52 / $48.52 / $48.52
| Facility | | $48.52 | $48.52 | $48.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.52 / $48.52 / $49.10
| Professional | | $48.52 | $48.52 | $49.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.70 / $82.84 / $93.32
| Professional | | $57.70 | $82.84 | $93.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.52 / $400.00 / $2,490.86
| Facility | | $48.52 | $400.00 | $2,490.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.72 / $72.23 / $588.60
| Professional | | $53.72 | $72.23 | $588.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $610.00 / $1,883.00
| Facility | | $100.00 | $610.00 | $1,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.39 / $70.66 / $101.81
| Professional | | $51.39 | $70.66 | $101.81 |