- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.00 / $211.00 / $329.69
| Facility | | $211.00 | $211.00 | $329.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.06 / $298.50 / $329.69
| Professional | | $198.06 | $298.50 | $329.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.76 / $291.76 / $291.76
| Professional | | $291.76 | $291.76 | $291.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.90 / $228.90 / $228.90
| Facility | | $228.90 | $228.90 | $228.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.57 / $194.57 / $228.90
| Professional | | $194.57 | $194.57 | $228.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.84 / $187.84 / $297.41
| Professional | | $121.84 | $187.84 | $297.41 |