- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.83 / $36.83 / $36.83
| Facility | | $36.83 | $36.83 | $36.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.36 / $26.31 / $26.31
| Professional | | $9.36 | $26.31 | $26.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.75 / $15.15 / $15.15
| Professional | | $13.75 | $15.15 | $15.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.04 / $145.26 / $157.50
| Professional | | $110.04 | $145.26 | $157.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.27 / $204.75 / $269.45
| Professional | | $123.27 | $204.75 | $269.45 |