- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.10 / $241.43 / $6,496.99
| Facility | | $85.10 | $241.43 | $6,496.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.92 / $92.92 / $92.92
| Professional | | $92.92 | $92.92 | $92.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.99 / $135.81 / $267.80
| Facility | | $91.99 | $135.81 | $267.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Professional | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Facility | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Professional | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $92.72 / $111.77
| Professional | | $89.34 | $92.72 | $111.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,925.13 / $5,925.13 / $11,511.40
| Facility | | $5,925.13 | $5,925.13 | $11,511.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.41 / $94.48 / $590.46
| Professional | | $80.41 | $94.48 | $590.46 |