- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.02 / $256.02 / $256.02
| Facility | | $256.02 | $256.02 | $256.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.02 / $283.97 / $349.07
| Professional | | $256.02 | $283.97 | $349.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.67 / $42.67 / $42.67
| Professional | | $42.67 | $42.67 | $42.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.33 / $34.33 / $698.44
| Professional | | $34.33 | $34.33 | $698.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.81 / $256.02 / $336.03
| Facility | | $32.81 | $256.02 | $336.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.45 / $25.15 / $51.63
| Professional | | $15.45 | $25.15 | $51.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.45 / $25.15 / $51.63
| Professional | | $15.45 | $25.15 | $51.63 |