- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.08 / $126.08 / $184.50
| Facility | | $126.08 | $126.08 | $184.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $130.69 / $184.50
| Professional | | $123.00 | $130.69 | $184.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.69 / $130.69 / $130.69
| Facility | | $130.69 | $130.69 | $130.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.69 / $130.69 / $130.69
| Professional | | $130.69 | $130.69 | $130.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.72 / $128.13 / $166.57
| Professional | | $121.72 | $128.13 | $166.57 |