- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.74 / $161.74 / $161.74
| Facility | | $161.74 | $161.74 | $161.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.74 / $236.07 / $236.07
| Professional | | $161.74 | $236.07 | $236.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.85 / $245.75 / $251.87
| Professional | | $207.85 | $245.75 | $251.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.63 / $329.89 / $414.81
| Professional | | $326.63 | $329.89 | $414.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.94 / $193.46 / $1,170.00
| Facility | | $123.94 | $193.46 | $1,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.56 / $166.36 / $184.84
| Professional | | $88.56 | $166.36 | $184.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.94 / $166.36 / $184.84
| Professional | | $73.94 | $166.36 | $184.84 |