- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $83.18 / $251.19
| Professional | | $61.66 | $83.18 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $6,025.60
| Professional | | $125.89 | $125.89 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,096.48
| Professional | | $794.33 | $794.33 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $234.42 / $8,511.38
| Facility | | $134.90 | $234.42 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $194.98 / $275.42
| Professional | | $141.25 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $213.80 / $338.84
| Professional | | $131.83 | $213.80 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $1,445.44
| Professional | | $125.89 | $125.89 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $3,090.30
| Facility | | $1,445.44 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $331.13 / $1,445.44
| Professional | | $125.89 | $331.13 | $1,445.44 |