- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.84 / $161.84 / $282.57
| Facility | | $161.84 | $161.84 | $282.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.84 / $256.88 / $282.57
| Professional | | $161.84 | $256.88 | $282.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.35 / $616.35 / $677.99
| Facility | | $616.35 | $616.35 | $677.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.00 / $587.00 / $587.00
| Professional | | $587.00 | $587.00 | $587.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $42.50 / $50.00
| Professional | | $21.25 | $42.50 | $50.00 |