- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.39 / $124.39 / $124.39
| Facility | | $124.39 | $124.39 | $124.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.39 / $124.39 / $124.39
| Professional | | $124.39 | $124.39 | $124.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.00 / $163.00 / $207.76
| Professional | | $163.00 | $163.00 | $207.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.63 / $138.63 / $138.63
| Professional | | $138.63 | $138.63 | $138.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.55 / $197.55 / $603.30
| Professional | | $197.55 | $197.55 | $603.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.08 / $151.62 / $318.93
| Professional | | $101.08 | $151.62 | $318.93 |