- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.06 / $9,643.45 / $9,643.45
| Facility | | $120.06 | $9,643.45 | $9,643.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.75 / $115.53 / $192.54
| Professional | | $93.75 | $115.53 | $192.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.38 / $123.06 / $134.08
| Facility | | $113.38 | $123.06 | $134.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.78 / $119.18 / $146.04
| Professional | | $114.78 | $119.18 | $146.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.81 / $181.81 / $181.81
| Facility | | $181.81 | $181.81 | $181.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.33 / $140.58 / $511.40
| Professional | | $103.33 | $140.58 | $511.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.75 / $167.75 / $167.75
| Professional | | $167.75 | $167.75 | $167.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.32 / $135.63 / $306.23
| Professional | | $86.32 | $135.63 | $306.23 |