- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.37 / $291.62 / $291.62
| Facility | | $149.37 | $291.62 | $291.62 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $74.69 / $74.69 / $145.81
| Facility | 52 | $74.69 | $74.69 | $145.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.08 / $402.08 / $828.18
| Facility | | $193.08 | $402.08 | $828.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.31 / $565.17 / $1,386.25
| Facility | | $361.31 | $565.17 | $1,386.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.11 / $395.59 / $534.94
| Professional | | $238.11 | $395.59 | $534.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |