- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.21 / $347.21 / $508.50
| Facility | | $347.21 | $347.21 | $508.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.00 / $162.38 / $410.00
| Professional | | $92.00 | $162.38 | $410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $110.00 / $200.00
| Professional | | $100.00 | $110.00 | $200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.92 / $172.92 / $172.92
| Facility | | $172.92 | $172.92 | $172.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $1,427.00 / $1,998.00
| Facility | | $200.00 | $1,427.00 | $1,998.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.57 / $298.00 / $298.00
| Professional | | $34.57 | $298.00 | $298.00 |