- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Facility | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $245.47 / $467.74
| Professional | | $147.91 | $245.47 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $239.88 / $371.54
| Professional | | $154.88 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $323.59 / $549.54
| Professional | | $194.98 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $389.05 / $630.96
| Professional | | $190.55 | $389.05 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Facility | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $295.12 / $691.83
| Professional | | $162.18 | $295.12 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $251.19 / $575.44
| Professional | | $154.88 | $251.19 | $575.44 |