- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.88 / $21.88 / $21.88
| Facility | | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $25.12 / $52.48
| Professional | | $19.50 | $25.12 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $131.83 / $204.17
| Professional | | $104.71 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $100.00
| Professional | | $60.26 | $60.26 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $75.86
| Professional | | $50.12 | $60.26 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $52.48 / $85.11
| Professional | | $41.69 | $52.48 | $85.11 |