- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.11 / $317.11 / $317.11
| Facility | | $317.11 | $317.11 | $317.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.10 / $301.17 / $317.11
| Professional | | $160.10 | $301.17 | $317.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.52 / $224.64 / $448.13
| Professional | | $106.52 | $224.64 | $448.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.36 / $386.66 / $584.40
| Professional | | $316.36 | $386.66 | $584.40 |