- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.60 / $253.60 / $253.60
| Facility | | $253.60 | $253.60 | $253.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.60 / $253.60 / $253.60
| Professional | | $253.60 | $253.60 | $253.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.25 / $35.50 / $35.50
| Professional | | $29.25 | $35.50 | $35.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $60.20
| Facility | | $50.00 | $50.00 | $60.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.94 / $23.44 / $50.00
| Professional | | $18.94 | $23.44 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.15 / $244.15 / $256.50
| Professional | | $244.15 | $244.15 | $256.50 |