- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.50 / $337.50 / $2,286.51
| Facility | | $337.50 | $337.50 | $2,286.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.50 / $337.50 / $337.50
| Professional | | $337.50 | $337.50 | $337.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.14 / $506.25 / $665.35
| Professional | | $482.14 | $506.25 | $665.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.21 / $977.78 / $2,749.06
| Facility | | $766.21 | $977.78 | $2,749.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.07 / $482.14 / $578.57
| Facility | | $376.07 | $482.14 | $578.57 |
- 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
- $87.07 / $124.39 / $248.77
| Professional | | $87.07 | $124.39 | $248.77 |