- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $1,198.79 / $14,038.18
| Facility | | $89.34 | $1,198.79 | $14,038.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $90.24 / $136.69
| Professional | | $89.34 | $90.24 | $136.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $148.66 / $284.99
| Facility | | $89.34 | $148.66 | $284.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Professional | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.29 / $89.34 / $89.34
| Facility | | $84.29 | $89.34 | $89.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Professional | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Facility | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $94.70 / $117.93
| Professional | | $89.34 | $94.70 | $117.93 |