- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $246.23
| Facility | | $246.23 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $246.23 / $246.23
| Professional | | $112.20 | $246.23 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.04 / $179.36 / $318.13
| Facility | | $76.04 | $179.36 | $318.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.21 / $471.78 / $615.53
| Facility | | $44.21 | $471.78 | $615.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.47 / $246.23 / $362.23
| Facility | | $122.47 | $246.23 | $362.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |