- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $291.25
| Facility | | $242.71 | $242.71 | $291.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $311.20
| Professional | | $242.71 | $242.71 | $311.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.79 / $204.20 / $500.00
| Professional | | $124.79 | $204.20 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $400.00 / $493.00
| Professional | | $200.00 | $400.00 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.94 / $615.94 / $615.94
| Facility | | $615.94 | $615.94 | $615.94 |