- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.78 / $758.54 / $833.56
| Facility | | $416.78 | $758.54 | $833.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.26 / $758.54 / $833.56
| Professional | | $329.26 | $758.54 | $833.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.00 / $24.00 / $24.00
| Facility | | $24.00 | $24.00 | $24.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $24.00 / $24.00
| Professional | | $24.00 | $24.00 | $24.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.05 / $250.07 / $711.43
| Professional | | $175.05 | $250.07 | $711.43 |