- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.54 / $50.00 / $50.00
| Facility | | $38.54 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.83 / $50.00 / $52.17
| Professional | | $42.83 | $50.00 | $52.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.55 / $23.00 / $29.40
| Professional | | $19.55 | $23.00 | $29.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53,899.46 / $53,899.46 / $53,899.46
| Facility | | $53,899.46 | $53,899.46 | $53,899.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $45.00
| Professional | | $45.00 | $45.00 | $45.00 |