- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $556.63
| Facility | | $225.00 | $225.00 | $556.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $362.81 / $743.15
| Professional | | $225.00 | $362.81 | $743.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.05 / $671.34 / $676.35
| Professional | | $572.05 | $671.34 | $676.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.49 / $105.53 / $132.69
| Professional | | $104.49 | $105.53 | $132.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $382.50
| Facility | | $225.00 | $225.00 | $382.50 |