- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.05 / $160.00 / $160.00
| Facility | | $90.05 | $160.00 | $160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.55 / $114.56 / $160.00
| Professional | | $96.55 | $114.56 | $160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $150.00 / $159.25
| Professional | | $130.00 | $150.00 | $159.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.83 / $156.56 / $203.12
| Facility | | $111.83 | $156.56 | $203.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.83 / $139.79 / $157.68
| Professional | | $111.83 | $139.79 | $157.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $45.00
| Professional | | $45.00 | $45.00 | $45.00 |