- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.08 / $376.69 / $2,969.11
| Facility | | $325.08 | $376.69 | $2,969.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.69 / $376.69 / $376.69
| Professional | | $376.69 | $376.69 | $376.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.62 / $495.36 / $990.72
| Facility | | $291.62 | $495.36 | $990.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.00 / $538.66 / $538.66
| Facility | | $255.00 | $538.66 | $538.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.69 / $538.66 / $538.66
| Facility | | $376.69 | $538.66 | $538.66 |