- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Facility | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $549.54
| Professional | | $34.67 | $44.67 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $575.44
| Professional | | $331.13 | $478.63 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $83.18 / $100.00
| Professional | | $50.12 | $83.18 | $100.00 |