- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.88 / $177.88 / $177.88
| Facility | | $177.88 | $177.88 | $177.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.24 / $178.48 / $214.06
| Professional | | $160.24 | $178.48 | $214.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.55 / $204.46 / $204.46
| Professional | | $197.55 | $204.46 | $204.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.46 / $204.46 / $204.46
| Professional | | $204.46 | $204.46 | $204.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.05 / $45.05 / $45.05
| Professional | | $45.05 | $45.05 | $45.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.00 / $187.88 / $232.02
| Facility | | $155.00 | $187.88 | $232.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |