- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,088.80 / $21,088.80 / $21,088.80
| Facility | | $21,088.80 | $21,088.80 | $21,088.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.89 / $87.53 / $178.95
| Professional | | $85.89 | $87.53 | $178.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.31 / $68,999.99 / $94,999.99
| Facility | | $78.31 | $68,999.99 | $94,999.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.48 / $92.48 / $197.79
| Facility | | $92.48 | $92.48 | $197.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.79 / $78.79 / $92.48
| Professional | | $78.79 | $78.79 | $92.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.48 / $92.48 / $197.79
| Facility | | $92.48 | $92.48 | $197.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.79 / $85.48 / $111.50
| Professional | | $78.79 | $85.48 | $111.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.80 / $78.80 / $78.80
| Professional | | $78.80 | $78.80 | $78.80 |