- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.61 / $136.61 / $136.61
| Facility | | $136.61 | $136.61 | $136.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.61 / $136.61 / $136.61
| Professional | | $136.61 | $136.61 | $136.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.08 / $195.88 / $197.87
| Professional | | $178.08 | $195.88 | $197.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.68 / $210.68 / $210.68
| Facility | | $210.68 | $210.68 | $210.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.68 / $350.00 / $502.03
| Professional | | $210.68 | $350.00 | $502.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.57 / $239.07 / $1,166.45
| Facility | | $125.57 | $239.07 | $1,166.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.48 / $130.66 / $224.31
| Professional | | $86.48 | $130.66 | $224.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.44 / $319.74 / $506.55
| Facility | | $268.44 | $319.74 | $506.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.12 / $389.02 / $551.29
| Professional | | $267.12 | $389.02 | $551.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.56 / $129.71 / $216.83
| Professional | | $81.56 | $129.71 | $216.83 |