- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.71 / $127.71 / $127.71
| Facility | | $127.71 | $127.71 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.71 / $127.71 / $127.71
| Professional | | $127.71 | $127.71 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.00 / $128.00 / $128.00
| Professional | | $128.00 | $128.00 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $121.52 / $121.52
| Professional | | $121.52 | $121.52 | $121.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.74 / $155.74 / $475.61
| Professional | | $155.74 | $155.74 | $475.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $119.53 / $169.34
| Professional | | $79.69 | $119.53 | $169.34 |