- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.69 / $140.69 / $140.69
| Facility | | $140.69 | $140.69 | $140.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.69 / $140.69 / $140.69
| Professional | | $140.69 | $140.69 | $140.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.15 / $209.15 / $235.00
| Professional | | $209.15 | $209.15 | $235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.47 / $155.47 / $155.47
| Professional | | $155.47 | $155.47 | $155.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.46 / $223.46 / $682.42
| Professional | | $223.46 | $223.46 | $682.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.34 / $171.50 / $257.68
| Professional | | $114.34 | $171.50 | $257.68 |