- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.74 / $299.74 / $299.74
| Facility | | $299.74 | $299.74 | $299.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.74 / $299.74 / $552.00
| Professional | | $299.74 | $299.74 | $552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.10 / $198.80 / $206.50
| Professional | | $122.10 | $198.80 | $206.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.48 / $193.97 / $228.20
| Professional | | $81.48 | $193.97 | $228.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.95 / $888.12 / $1,518.64
| Professional | | $49.95 | $888.12 | $1,518.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.00 / $10,320.00 / $10,320.00
| Professional | | $2,790.00 | $10,320.00 | $10,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.20 / $1,263.59 / $1,624.87
| Professional | | $80.20 | $1,263.59 | $1,624.87 |