- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.63 / $145.63 / $145.63
| Facility | | $145.63 | $145.63 | $145.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.13 / $145.63 / $145.63
| Professional | | $139.13 | $145.63 | $145.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.69 / $180.78 / $180.78
| Professional | | $162.69 | $180.78 | $180.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.84 / $161.68 / $270.32
| Professional | | $147.84 | $161.68 | $270.32 |