- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Facility | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $250.00 / $318.75
| Professional | | $250.00 | $250.00 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,520.00 / $1,520.00
| Facility | | $1,520.00 | $1,520.00 | $1,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $538.69 / $715.28
| Facility | | $422.50 | $538.69 | $715.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.42 / $227.99 / $626.15
| Facility | | $195.42 | $227.99 | $626.15 |