- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.68 / $693.88 / $832.66
| Facility | | $455.68 | $693.88 | $832.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.47 / $693.88 / $832.66
| Professional | | $18.47 | $693.88 | $832.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $1,093.56
| Professional | | $440.40 | $440.40 | $1,093.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |