- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.80 / $849.86 / $876.26
| Facility | | $814.80 | $849.86 | $876.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,149.24 / $2,243.65 / $2,243.65
| Facility | | $1,149.24 | $2,243.65 | $2,243.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.70 / $635.70 / $635.70
| Facility | | $635.70 | $635.70 | $635.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.42 / $856.37 / $2,730.94
| Professional | | $591.42 | $856.37 | $2,730.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |