- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.45 / $262.45 / $262.45
| Facility | | $262.45 | $262.45 | $262.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.55 / $106.35 / $106.35
| Professional | | $81.55 | $106.35 | $106.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.06 / $1,037.06 / $1,083.50
| Facility | | $1,037.06 | $1,037.06 | $1,083.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.38 / $167.38 / $167.38
| Facility | | $167.38 | $167.38 | $167.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.61 / $100.62 / $143.52
| Professional | | $50.61 | $100.62 | $143.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.38 / $167.38 / $167.38
| Facility | | $167.38 | $167.38 | $167.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.61 / $100.62 / $143.52
| Professional | | $50.61 | $100.62 | $143.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.68 / $60.00 / $131.94
| Professional | | $43.68 | $60.00 | $131.94 |