- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.96 / $184.96 / $184.96
| Facility | | $184.96 | $184.96 | $184.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.82 / $184.96 / $199.72
| Professional | | $152.82 | $184.96 | $199.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.16 / $2,216.51 / $3,868.86
| Facility | | $1,057.16 | $2,216.51 | $3,868.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.86 / $184.96 / $314.43
| Facility | | $135.86 | $184.96 | $314.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |