- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.36 / $174.36 / $174.36
| Facility | | $174.36 | $174.36 | $174.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.31 / $190.88 / $237.83
| Professional | | $160.31 | $190.88 | $237.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.75 / $147.47 / $213.63
| Facility | | $108.75 | $147.47 | $213.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.48 / $77.48 / $116.23
| Professional | | $77.48 | $77.48 | $116.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,713.00 / $1,713.00 / $2,248.00
| Facility | | $1,713.00 | $1,713.00 | $2,248.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.27 / $146.27 / $146.27
| Professional | | $146.27 | $146.27 | $146.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.36 / $190.88 / $240.00
| Facility | | $174.36 | $190.88 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.63 / $198.78 / $1,234.73
| Professional | | $159.63 | $198.78 | $1,234.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.11 / $195.10 / $363.96
| Professional | | $161.11 | $195.10 | $363.96 |