- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.33 / $153.33 / $809.44
| Facility | | $153.33 | $153.33 | $809.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.49 / $174.54 / $298.43
| Professional | | $150.49 | $174.54 | $298.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.37 / $304.37 / $391.93
| Professional | | $304.37 | $304.37 | $391.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.06 / $306.73 / $306.73
| Professional | | $203.06 | $306.73 | $306.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.18 / $229.50 / $243.27
| Facility | | $182.18 | $229.50 | $243.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.54 / $167.54 / $229.50
| Professional | | $167.54 | $167.54 | $229.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.55 / $1,920.53 / $2,158.44
| Facility | | $615.55 | $1,920.53 | $2,158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.81 / $2,438.96 / $2,922.75
| Professional | | $2,381.81 | $2,438.96 | $2,922.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.35 / $168.51 / $243.93
| Professional | | $113.35 | $168.51 | $243.93 |