- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.26 / $427.95 / $6,704.97
| Facility | | $133.26 | $427.95 | $6,704.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $133.26 / $133.26
| Professional | | $117.25 | $133.26 | $133.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $231.07 / $310.82
| Professional | | $144.47 | $231.07 | $310.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.00 / $133.26 / $223.81
| Facility | | $110.00 | $133.26 | $223.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.82 / $110.82 / $110.82
| Professional | | $110.82 | $110.82 | $110.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.50 / $162.50 / $249.70
| Professional | | $162.50 | $162.50 | $249.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.00 / $190.00 / $301.00
| Professional | | $159.00 | $190.00 | $301.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.25 / $5,062.89 / $5,062.89
| Facility | | $242.25 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.03 / $850.03 / $1,198.95
| Professional | | $850.03 | $850.03 | $1,198.95 |