- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.84 / $105.84 / $105.84
| Facility | | $105.84 | $105.84 | $105.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.74 / $104.74 / $104.74
| Professional | | $104.74 | $104.74 | $104.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.80 / $436.51 / $488.59
| Professional | | $358.80 | $436.51 | $488.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.92 / $105.23 / $131.54
| Professional | | $78.92 | $105.23 | $131.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $40.00 / $60.00
| Professional | | $35.00 | $40.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |