- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.88 / $229.09 / $251.36
| Facility | | $177.88 | $229.09 | $251.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.88 / $251.36 / $300.44
| Professional | | $177.88 | $251.36 | $300.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.77 / $281.77 / $281.77
| Professional | | $281.77 | $281.77 | $281.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.27 / $238.77 / $319.45
| Professional | | $189.27 | $238.77 | $319.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.00 / $441.00 / $441.00
| Professional | | $441.00 | $441.00 | $441.00 |