- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.28 / $128.28 / $128.28
| Facility | | $128.28 | $128.28 | $128.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.10 / $123.69 / $200.08
| Professional | | $89.10 | $123.69 | $200.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.42 / $96.42 / $394.13
| Professional | | $96.42 | $96.42 | $394.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.42 / $96.42 / $394.13
| Professional | | $96.42 | $96.42 | $394.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.68 / $158.88 / $459.33
| Professional | | $108.68 | $158.88 | $459.33 |