- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $138.04 / $275.42
| Professional | | $109.65 | $138.04 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $3,981.07 / $6,309.57
| Facility | | $331.13 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $218.78 / $851.14
| Professional | | $141.25 | $218.78 | $851.14 |
- 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
- $190.55 / $190.55 / $223.87
| Professional | | $190.55 | $190.55 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $295.12 / $426.58
| Professional | | $165.96 | $295.12 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $3,981.07 / $6,309.57
| Facility | | $331.13 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $218.78 / $851.14
| Professional | | $141.25 | $218.78 | $851.14 |