- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.95 / $862.10 / $1,935.76
| Facility | | $333.95 | $862.10 | $1,935.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.18 / $314.18 / $436.73
| Professional | | $314.18 | $314.18 | $436.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.56 / $521.19 / $658.93
| Facility | | $435.56 | $521.19 | $658.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.02 / $52.02 / $52.02
| Professional | | $52.02 | $52.02 | $52.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |