- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.61 / $513.65 / $540.55
| Facility | | $488.61 | $513.65 | $540.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.67 / $1,261.80 / $1,261.80
| Facility | | $676.67 | $1,261.80 | $1,261.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.54 / $382.54 / $382.54
| Facility | | $382.54 | $382.54 | $382.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.88 / $519.65 / $1,732.18
| Professional | | $358.88 | $519.65 | $1,732.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |