- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.27 / $141.27 / $2,049.94
| Facility | | $141.27 | $141.27 | $2,049.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.73 / $141.27 / $336.20
| Professional | | $86.73 | $141.27 | $336.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.67 / $118.85 / $198.45
| Professional | | $103.67 | $118.85 | $198.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.47 / $141.27 / $352.08
| Professional | | $116.47 | $141.27 | $352.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.46 / $112.94 / $175.73
| Professional | | $101.46 | $112.94 | $175.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,049.94 / $2,049.94 / $2,049.94
| Facility | | $2,049.94 | $2,049.94 | $2,049.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.73 / $141.27 / $336.20
| Professional | | $86.73 | $141.27 | $336.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.47 / $343.40 / $457.55
| Professional | | $139.47 | $343.40 | $457.55 |