- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.50 / $472.50 / $652.50
| Facility | | $472.50 | $472.50 | $652.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $326.25 / $472.50
| Professional | | $225.00 | $326.25 | $472.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.50 / $450.00 / $506.25
| Professional | | $337.50 | $450.00 | $506.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.75 / $483.62 / $703.36
| Facility | | $243.75 | $483.62 | $703.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.50 / $225.00 / $375.00
| Professional | | $157.50 | $225.00 | $375.00 |