- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.65 / $176.65 / $176.65
| Facility | | $176.65 | $176.65 | $176.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.65 / $412.43 / $429.48
| Professional | | $176.65 | $412.43 | $429.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $623.13 / $716.47
| Facility | | $100.00 | $623.13 | $716.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.32 / $168.32 / $168.32
| Professional | | $168.32 | $168.32 | $168.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.12 / $567.12 / $567.12
| Professional | | $567.12 | $567.12 | $567.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $3,472.00 / $9,239.00
| Facility | | $83.43 | $3,472.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.47 / $128.47 / $167.14
| Professional | | $128.47 | $128.47 | $167.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.32 / $168.32 / $168.32
| Professional | | $168.32 | $168.32 | $168.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.47 / $128.47 / $128.47
| Professional | | $128.47 | $128.47 | $128.47 |