- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $131.83 / $239.88
| Professional | | $93.33 | $131.83 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $3,715.35 / $6,309.57
| Facility | | $147.91 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $724.44
| Professional | | $112.20 | $169.82 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $3,630.78 / $9,772.37
| Facility | | $83.18 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $194.98
| Professional | | $165.96 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $234.42 / $346.74
| Professional | | $131.83 | $234.42 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,762.47 / $7,762.47
| Facility | | $4,073.80 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $3,715.35 / $6,309.57
| Facility | | $147.91 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $724.44
| Professional | | $112.20 | $169.82 | $724.44 |