- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $131.72
| Facility | | $131.72 | $131.72 | $131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $131.72 / $137.68
| Professional | | $106.45 | $131.72 | $137.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.76 / $75.00 / $100.00
| Professional | | $49.76 | $75.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $184.41
| Facility | | $131.72 | $131.72 | $184.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $85.00 / $100.00
| Facility | | $64.00 | $85.00 | $100.00 |