- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.42 / $274.08 / $477.75
| Facility | | $207.42 | $274.08 | $477.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.52 / $426.62 / $554.79
| Facility | | $270.52 | $426.62 | $554.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.65 / $304.69 / $347.39
| Professional | | $214.65 | $304.69 | $347.39 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $67.43 / $67.43 / $67.43
| Professional | 80 | $67.43 | $67.43 | $67.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |