- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.65 / $90.65 / $108.78
| Facility | | $90.65 | $90.65 | $108.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.06 / $80.06 / $90.65
| Professional | | $80.06 | $80.06 | $90.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.25 / $140.25 / $140.25
| Professional | | $140.25 | $140.25 | $140.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.28 / $40.28 / $100.02
| Professional | | $40.28 | $40.28 | $100.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.28 / $40.28 / $40.28
| Professional | | $40.28 | $40.28 | $40.28 |