- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.39 / $490.39 / $3,322.36
| Facility | | $490.39 | $490.39 | $3,322.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.39 / $490.39 / $490.39
| Professional | | $490.39 | $490.39 | $490.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.56 / $735.59 / $966.77
| Professional | | $700.56 | $735.59 | $966.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.44 / $700.56 / $840.67
| Facility | | $546.44 | $700.56 | $840.67 |
- 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
- $294.24 / $420.34 / $637.94
| Professional | | $294.24 | $420.34 | $637.94 |