- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.56 / $177.56 / $926.64
| Facility | | $177.56 | $177.56 | $926.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.56 / $177.56 / $177.56
| Professional | | $177.56 | $177.56 | $177.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.63 / $319.61 / $805.44
| Facility | | $211.63 | $319.61 | $805.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.87 / $158.87 / $177.56
| Professional | | $158.87 | $158.87 | $177.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Facility | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Professional | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.30 / $288.36 / $548.04
| Professional | | $186.30 | $288.36 | $548.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.21 / $155.75 / $186.90
| Professional | | $144.21 | $155.75 | $186.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.68 / $187.23 / $3,000.00
| Professional | | $149.68 | $187.23 | $3,000.00 |