- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.34 / $264.67 / $6,254.44
| Facility | | $78.34 | $264.67 | $6,254.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.44 / $178.21 / $1,723.22
| Professional | | $176.44 | $178.21 | $1,723.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.41 / $155.41 / $176.45
| Professional | | $155.41 | $155.41 | $176.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.41 / $172.29 / $195.05
| Professional | | $155.41 | $172.29 | $195.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $180.79
| Facility | | $176.45 | $176.45 | $180.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Professional | | $176.45 | $176.45 | $176.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.03 / $1,272.84 / $1,413.42
| Facility | | $542.03 | $1,272.84 | $1,413.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.46 / $2,475.46 / $2,475.46
| Professional | | $2,475.46 | $2,475.46 | $2,475.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.63 / $176.45 / $208.21
| Professional | | $167.63 | $176.45 | $208.21 |