- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $266.69
| Facility | | $254.57 | $254.57 | $266.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.91 / $203.42 / $266.69
| Professional | | $148.91 | $203.42 | $266.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.38 / $4.38 / $112.60
| Professional | | $4.38 | $4.38 | $112.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $200.00 / $229.28
| Professional | | $127.38 | $200.00 | $229.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $191.07
| Professional | | $127.38 | $127.38 | $191.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $254.57
| Professional | | $254.57 | $254.57 | $254.57 |