- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.52 / $307.52 / $307.52
| Facility | | $307.52 | $307.52 | $307.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.29 / $16.29 / $307.52
| Professional | | $16.29 | $16.29 | $307.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.33 / $281.33 / $281.33
| Professional | | $281.33 | $281.33 | $281.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.29 / $17.10 / $35.02
| Facility | | $16.29 | $17.10 | $35.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.03 / $511.46 / $689.17
| Facility | | $410.03 | $511.46 | $689.17 |