- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.52 / $9,871.36 / $9,871.36
| Facility | | $172.52 | $9,871.36 | $9,871.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.34 / $77.33 / $90.08
| Professional | | $74.34 | $77.33 | $90.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.14 / $82.67 / $235.65
| Facility | | $66.14 | $82.67 | $235.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $77.16
| Professional | | $74.36 | $74.36 | $77.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.91 / $74.36 / $85.00
| Facility | | $72.91 | $74.36 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.05 / $90.05 / $90.05
| Facility | | $90.05 | $90.05 | $90.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.52 / $172.52 / $9,871.36
| Facility | | $172.52 | $172.52 | $9,871.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $78.08 / $102.11
| Professional | | $74.36 | $78.08 | $102.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $107.82
| Professional | | $74.36 | $74.36 | $107.82 |