- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.54 / $484.39 / $2,139.19
| Facility | | $176.54 | $484.39 | $2,139.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $187.57
| Professional | | $176.54 | $176.54 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.88 / $241.09 / $312.55
| Facility | | $184.88 | $241.09 | $312.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.57 / $201.75 / $302.63
| Facility | | $187.57 | $201.75 | $302.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $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 |