- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $156.65
| Professional | | $120.36 | $120.36 | $156.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.00 / $158.00 / $158.00
| Professional | | $158.00 | $158.00 | $158.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.27 / $139.27 / $139.27
| Professional | | $139.27 | $139.27 | $139.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.15 / $191.15 / $583.75
| Professional | | $191.15 | $191.15 | $583.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.80 / $146.71 / $220.43
| Professional | | $97.80 | $146.71 | $220.43 |