- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.39 / $275.39 / $275.39
| Facility | | $275.39 | $275.39 | $275.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.39 / $275.39 / $396.37
| Professional | | $275.39 | $275.39 | $396.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.96 / $207.29 / $825.00
| Professional | | $123.96 | $207.29 | $825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.82 / $315.82 / $315.82
| Professional | | $315.82 | $315.82 | $315.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.50 / $50.00 / $80.00
| Professional | | $42.50 | $50.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.61 / $385.63 / $749.22
| Professional | | $316.61 | $385.63 | $749.22 |