- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.64 / $175.64 / $175.64
| Facility | | $175.64 | $175.64 | $175.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.64 / $175.64 / $175.64
| Professional | | $175.64 | $175.64 | $175.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.00 / $230.00 / $293.36
| Professional | | $230.00 | $230.00 | $293.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.48 / $230.48 / $230.48
| Professional | | $230.48 | $230.48 | $230.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.94 / $278.94 / $851.86
| Professional | | $278.94 | $278.94 | $851.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.72 / $214.10 / $333.24
| Professional | | $142.72 | $214.10 | $333.24 |