- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.54 / $192.54 / $192.54
| Facility | | $192.54 | $192.54 | $192.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.65 / $192.54 / $192.54
| Professional | | $156.65 | $192.54 | $192.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $215.91 / $358.09
| Professional | | $100.00 | $215.91 | $358.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.54 / $192.54 / $205.55
| Facility | | $192.54 | $192.54 | $205.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.94 / $198.94 / $198.94
| Professional | | $198.94 | $198.94 | $198.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.00 / $299.75 / $396.95
| Professional | | $197.00 | $299.75 | $396.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.27 / $347.11 / $934.12
| Facility | | $306.27 | $347.11 | $934.12 |