- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.67 / $575.67 / $575.67
| Facility | | $575.67 | $575.67 | $575.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.48 / $207.64 / $575.67
| Professional | | $119.48 | $207.64 | $575.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.96 / $183.96 / $183.96
| Professional | | $183.96 | $183.96 | $183.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.60 / $119.70 / $174.44
| Facility | | $82.60 | $119.70 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.05 / $215.05 / $215.05
| Professional | | $215.05 | $215.05 | $215.05 |