- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.86 / $159.86 / $279.13
| Facility | | $159.86 | $159.86 | $279.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.86 / $253.75 / $279.13
| Professional | | $159.86 | $253.75 | $279.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.50 / $1,102.50 / $1,212.75
| Facility | | $1,102.50 | $1,102.50 | $1,212.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,050.00 / $1,050.00
| Professional | | $1,050.00 | $1,050.00 | $1,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $42.50 / $50.00
| Professional | | $21.25 | $42.50 | $50.00 |