- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.15 / $37.15 / $37.15
| Facility | | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $42.66 / $60.26
| Professional | | $34.67 | $42.66 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $186.21 / $208.93
| Professional | | $141.25 | $186.21 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |