- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.97 / $38.97 / $38.97
| Facility | | $38.97 | $38.97 | $38.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.70 / $191.07 / $749.38
| Professional | | $178.70 | $191.07 | $749.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.97 / $124.97 / $1,369.00
| Professional | | $124.97 | $124.97 | $1,369.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.85 / $311.64 / $414.43
| Professional | | $234.85 | $311.64 | $414.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.75 / $49.50 / $178.33
| Professional | | $33.75 | $49.50 | $178.33 |