- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.51 / $130.51 / $142.26
| Facility | | $130.51 | $130.51 | $142.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.15 / $142.26 / $142.26
| Professional | | $110.15 | $142.26 | $142.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.00 / $66.00 / $66.00
| Professional | | $66.00 | $66.00 | $66.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.51 / $142.26 / $156.49
| Facility | | $130.51 | $142.26 | $156.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |