- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.76 / $45.76 / $45.76
| Facility | | $45.76 | $45.76 | $45.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.76 / $45.76 / $216.80
| Professional | | $45.76 | $45.76 | $216.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $688.48 / $823.83 / $1,041.55
| Facility | | $688.48 | $823.83 | $1,041.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |