- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.87 / $237.75 / $387.00
| Facility | | $110.87 | $237.75 | $387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.95 / $237.75 / $447.24
| Professional | | $117.95 | $237.75 | $447.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.93 / $19.91 / $20.32
| Professional | | $14.93 | $19.91 | $20.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $100.00
| Professional | | $45.00 | $45.00 | $100.00 |