- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.81 / $46.81 / $46.81
| Facility | | $46.81 | $46.81 | $46.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.81 / $46.81 / $46.81
| Professional | | $46.81 | $46.81 | $46.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.20 / $640.00 / $1,281.59
| Facility | | $299.20 | $640.00 | $1,281.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |