- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $273.45
| Facility | | $273.45 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.00 / $273.45 / $273.45
| Professional | | $216.00 | $273.45 | $273.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.41 / $191.97 / $323.92
| Facility | | $108.41 | $191.97 | $323.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.21 / $471.78 / $1,090.33
| Facility | | $44.21 | $471.78 | $1,090.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.79 / $273.45 / $328.14
| Facility | | $104.79 | $273.45 | $328.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |