- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.00 / $226.50 / $283.50
| Facility | | $205.00 | $226.50 | $283.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.41 / $310.23 / $598.74
| Facility | | $126.41 | $310.23 | $598.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.86 / $334.39 / $464.60
| Professional | | $285.86 | $334.39 | $464.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.65 / $190.12 / $323.04
| Facility | | $101.65 | $190.12 | $323.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.66 / $0.66 / $0.66
| Professional | | $0.66 | $0.66 | $0.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.42 / $135.42 / $251.59
| Facility | | $135.42 | $135.42 | $251.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.87 / $185.87 / $185.87
| Professional | | $185.87 | $185.87 | $185.87 |