- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.27 / $272.27 / $340.34
| Professional | | $272.27 | $272.27 | $340.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $273.85
| Professional | | $150.00 | $150.00 | $273.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.00 / $167.00 / $167.00
| Facility | | $167.00 | $167.00 | $167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.00 / $167.00 / $471.07
| Professional | | $101.00 | $167.00 | $471.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.00 / $167.00 / $167.00
| Facility | | $167.00 | $167.00 | $167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.00 / $167.00 / $251.95
| Professional | | $101.00 | $167.00 | $251.95 |