- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.06 / $47.06 / $47.06
| Facility | | $47.06 | $47.06 | $47.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.06 / $47.06 / $53.03
| Professional | | $47.06 | $47.06 | $53.03 |
- 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
- $249.47 / $249.47 / $249.47
| Professional | | $249.47 | $249.47 | $249.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.06 / $47.06 / $77.83
| Facility | | $47.06 | $47.06 | $77.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.00 / $105.00 / $105.00
| Professional | | $105.00 | $105.00 | $105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |