- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Facility | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.75 / $175.28 / $175.28
| Professional | | $143.75 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.65 / $323.10 / $323.10
| Professional | | $141.65 | $323.10 | $323.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $190.55 / $392.63
| Facility | | $175.28 | $190.55 | $392.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.97 / $115.97 / $115.97
| Professional | | $115.97 | $115.97 | $115.97 |