- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.28 / $373.28 / $373.28
| Facility | | $373.28 | $373.28 | $373.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.61 / $37.61 / $65.31
| Professional | | $37.61 | $37.61 | $65.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $66.00 / $66.00
| Professional | | $53.00 | $66.00 | $66.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Facility | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.34 / $56.34 / $91.32
| Professional | | $43.34 | $56.34 | $91.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.50 / $39.70 / $111.16
| Professional | | $36.50 | $39.70 | $111.16 |