- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.89 / $673.45 / $1,287.58
| Facility | | $505.89 | $673.45 | $1,287.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.46 / $3.46 / $379.06
| Professional | | $3.46 | $3.46 | $379.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.64 / $397.64 / $397.64
| Facility | | $397.64 | $397.64 | $397.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.98 / $217.98 / $217.98
| Professional | | $217.98 | $217.98 | $217.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.46 / $4.15 / $269.62
| Facility | | $3.46 | $4.15 | $269.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |