- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.45 / $41.45 / $41.45
| Facility | | $41.45 | $41.45 | $41.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $41.45 / $57.17
| Professional | | $37.04 | $41.45 | $57.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.43 / $545.05 / $1,077.30
| Facility | | $115.43 | $545.05 | $1,077.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119,998.80 / $119,998.80 / $119,998.80
| Professional | | $119,998.80 | $119,998.80 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.84 / $48.84 / $48.84
| Facility | | $48.84 | $48.84 | $48.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.98 / $183.98 / $183.98
| Professional | | $183.98 | $183.98 | $183.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.20 / $66.19 / $101.02
| Professional | | $42.20 | $66.19 | $101.02 |