- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $252.64
| Professional | | $252.64 | $252.64 | $252.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.83 / $430.48 / $555.37
| Facility | | $360.83 | $430.48 | $555.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.40 / $105.40 / $105.40
| Professional | | $105.40 | $105.40 | $105.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $125.00 / $345.40
| Professional | | $100.00 | $125.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,500.00 / $2,500.00
| Professional | | $1,500.00 | $2,500.00 | $2,500.00 |