- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.32 / $687.48 / $1,374.87
| Facility | | $106.32 | $687.48 | $1,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.32 / $106.32 / $300.00
| Professional | | $106.32 | $106.32 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.99 / $109.99 / $109.99
| Professional | | $109.99 | $109.99 | $109.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $91.82 / $137.41
| Professional | | $45.00 | $91.82 | $137.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.58 / $450.58 / $450.58
| Professional | | $450.58 | $450.58 | $450.58 |