- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.97 / $552.65 / $5,239.97
| Facility | | $333.97 | $552.65 | $5,239.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $33.60 / $49.59
| Professional | | $30.00 | $33.60 | $49.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.15 / $746.15 / $911.96
| Facility | | $746.15 | $746.15 | $911.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,887.91 / $1,887.91 / $1,887.91
| Facility | | $1,887.91 | $1,887.91 | $1,887.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $100.00
| Professional | | $60.00 | $60.00 | $100.00 |