- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $261.80
| Facility | | $261.80 | $261.80 | $261.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $3,300.77
| Professional | | $261.80 | $261.80 | $3,300.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $346.50 / $346.50
| Professional | | $70.00 | $346.50 | $346.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.79 / $360.79 / $360.79
| Facility | | $360.79 | $360.79 | $360.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $445.06
| Facility | | $261.80 | $261.80 | $445.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |