- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.03 / $4,130.30 / $4,130.30
| Facility | | $196.03 | $4,130.30 | $4,130.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $242.31
| Professional | | $176.45 | $176.45 | $242.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.41 / $176.45 / $264.68
| Facility | | $155.41 | $176.45 | $264.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $200.76 / $409.11
| Professional | | $176.45 | $200.76 | $409.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.46 / $460.73 / $460.73
| Facility | | $166.46 | $460.73 | $460.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $206.75
| Professional | | $176.45 | $176.45 | $206.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.79 / $1,047.63 / $1,466.52
| Facility | | $180.79 | $1,047.63 | $1,466.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $195.86 / $1,526.08
| Professional | | $176.45 | $195.86 | $1,526.08 |