- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.51 / $328.51 / $1,912.74
| Facility | | $328.51 | $328.51 | $1,912.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.78 / $117.72 / $307.11
| Facility | | $93.78 | $117.72 | $307.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $145.76
| Professional | | $120.36 | $120.36 | $145.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.51 / $328.51 / $1,912.74
| Facility | | $328.51 | $328.51 | $1,912.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $354.00
| Professional | | $120.36 | $120.36 | $354.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $177.00
| Professional | | $118.00 | $118.00 | $177.00 |