- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $43,889.73
| Facility | | $172.40 | $172.40 | $43,889.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.26 / $172.40 / $192.68
| Professional | | $162.26 | $172.40 | $192.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.64 / $391.43 / $818.35
| Facility | | $189.64 | $391.43 | $818.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $202.82 / $431.47
| Professional | | $172.40 | $202.82 | $431.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.54 / $316.85 / $3,678.84
| Facility | | $166.54 | $316.85 | $3,678.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $206.47
| Professional | | $172.40 | $172.40 | $206.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.78 / $271.41 / $8,090.00
| Facility | | $171.78 | $271.41 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $210.98
| Professional | | $172.40 | $172.40 | $210.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.68 / $192.68 / $858.90
| Facility | | $192.68 | $192.68 | $858.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $202.82 / $770.72
| Professional | | $172.40 | $202.82 | $770.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $202.82 / $335.47
| Professional | | $172.40 | $202.82 | $335.47 |