- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.79 / $148.38 / $148.38
| Facility | | $102.79 | $148.38 | $148.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.38 / $148.38 / $148.38
| Professional | | $148.38 | $148.38 | $148.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.46 / $53.65 / $53.65
| Professional | | $21.46 | $53.65 | $53.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.10 / $175.22 / $275.37
| Facility | | $55.10 | $175.22 | $275.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.99 / $331.64 / $489.19
| Professional | | $231.99 | $331.64 | $489.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.46 / $53.65 / $53.65
| Professional | | $21.46 | $53.65 | $53.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.46 / $53.65 / $53.65
| Professional | | $21.46 | $53.65 | $53.65 |