- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $327.43
| Facility | | $327.43 | $327.43 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $390.48
| Professional | | $327.43 | $327.43 | $390.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $15.00 / $32.00
| Professional | | $15.00 | $15.00 | $32.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $350.00 / $493.00
| Professional | | $130.00 | $350.00 | $493.00 |