- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.50 / $320.14 / $320.60
| Facility | | $136.50 | $320.14 | $320.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.76 / $425.99 / $705.98
| Facility | | $223.76 | $425.99 | $705.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.53 / $1,251.76 / $2,020.54
| Facility | | $413.53 | $1,251.76 | $2,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- 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
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |