- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.20 / $249.20 / $249.20
| Facility | | $249.20 | $249.20 | $249.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.20 / $265.72 / $287.64
| Professional | | $249.20 | $265.72 | $287.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.87 / $248.87 / $248.87
| Professional | | $248.87 | $248.87 | $248.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.70 / $22.70 / $22.70
| Professional | | $22.70 | $22.70 | $22.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.58 / $250.57 / $1,000.00
| Professional | | $246.58 | $250.57 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.47 / $258.47 / $258.47
| Professional | | $258.47 | $258.47 | $258.47 |