- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.72 / $480.78 / $533.32
| Facility | | $262.72 | $480.78 | $533.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.55 / $480.78 / $533.32
| Professional | | $207.55 | $480.78 | $533.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $262.72
| Facility | | $262.72 | $262.72 | $262.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $262.72
| Professional | | $262.72 | $262.72 | $262.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $30.00 / $50.00
| Professional | | $21.25 | $30.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.34 / $157.63 / $448.46
| Professional | | $110.34 | $157.63 | $448.46 |