- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.37 / $194.37 / $194.37
| Facility | | $194.37 | $194.37 | $194.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.10 / $194.37 / $350.55
| Professional | | $187.10 | $194.37 | $350.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.63 / $366.77 / $2,434.42
| Facility | | $295.63 | $366.77 | $2,434.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.70 / $295.63 / $349.30
| Professional | | $168.70 | $295.63 | $349.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.07 / $400.48 / $400.48
| Professional | | $315.07 | $400.48 | $400.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.92 / $219.78 / $295.63
| Facility | | $38.92 | $219.78 | $295.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.92 / $219.78 / $646.88
| Professional | | $38.92 | $219.78 | $646.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.77 / $362.77 / $362.77
| Professional | | $362.77 | $362.77 | $362.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.63 / $295.63 / $295.63
| Professional | | $295.63 | $295.63 | $295.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,434.42 / $2,434.42
| Facility | | $100.00 | $2,434.42 | $2,434.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.47 / $240.20 / $347.85
| Professional | | $157.47 | $240.20 | $347.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.91 / $262.02 / $528.74
| Professional | | $164.91 | $262.02 | $528.74 |