- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.83 / $438.83 / $438.83
| Facility | | $438.83 | $438.83 | $438.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.72 / $438.83 / $868.37
| Professional | | $395.72 | $438.83 | $868.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.89 / $69.89 / $69.89
| Professional | | $69.89 | $69.89 | $69.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.30 / $53.02 / $292.97
| Professional | | $44.30 | $53.02 | $292.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.10 / $885.10 / $1,432.70
| Professional | | $141.10 | $885.10 | $1,432.70 |