- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Facility | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.07 / $237.07 / $318.75
| Professional | | $237.07 | $237.07 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,520.00 / $1,520.00
| Facility | | $1,520.00 | $1,520.00 | $1,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.65 / $538.69 / $715.28
| Facility | | $400.65 | $538.69 | $715.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.07 / $169.24 / $485.84
| Facility | | $145.07 | $169.24 | $485.84 |