- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.76 / $129.76 / $129.76
| Facility | | $129.76 | $129.76 | $129.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.76 / $129.76 / $129.76
| Professional | | $129.76 | $129.76 | $129.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $216.73
| Professional | | $170.00 | $170.00 | $216.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $149.72 / $149.72
| Professional | | $149.72 | $149.72 | $149.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.08 / $206.08 / $629.36
| Professional | | $206.08 | $206.08 | $629.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.45 / $158.16 / $332.71
| Professional | | $105.45 | $158.16 | $332.71 |