- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.96 / $540.96 / $946.68
| Facility | | $540.96 | $540.96 | $946.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.96 / $540.96 / $876.05
| Professional | | $540.96 | $540.96 | $876.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.37 / $485.37 / $485.37
| Professional | | $485.37 | $485.37 | $485.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.40 / $920.40 / $920.40
| Professional | | $920.40 | $920.40 | $920.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.40 / $1,274.40 / $1,274.40
| Professional | | $1,274.40 | $1,274.40 | $1,274.40 |