- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $308.72
| Facility | | $308.72 | $308.72 | $308.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.76 / $1,536.70 / $1,536.70
| Professional | | $49.76 | $1,536.70 | $1,536.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.42 / $455.42 / $678.27
| Facility | | $455.42 | $455.42 | $678.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,750.61
| Facility | | $100.00 | $100.00 | $1,750.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.37 / $651.37 / $837.48
| Professional | | $651.37 | $651.37 | $837.48 |