- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.65 / $785.65 / $785.65
| Facility | | $785.65 | $785.65 | $785.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $785.65 / $1,308.58
| Professional | | $785.65 | $785.65 | $1,308.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.41 / $191.97 / $323.92
| Facility | | $108.41 | $191.97 | $323.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.21 / $321.51 / $687.57
| Facility | | $44.21 | $321.51 | $687.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $598.50 / $785.65 / $989.92
| Facility | | $598.50 | $785.65 | $989.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |