- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $184.38
| Facility | | $184.38 | $184.38 | $184.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $208.14
| Professional | | $184.38 | $184.38 | $208.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,101.36 / $2,101.36 / $2,101.36
| Facility | | $2,101.36 | $2,101.36 | $2,101.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.24 / $890.04 / $955.16
| Facility | | $466.24 | $890.04 | $955.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.28 / $71.28 / $71.28
| Professional | | $71.28 | $71.28 | $71.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |