- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $190.55 / $1,862.09
| Professional | | $102.33 | $190.55 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $234.42
| Professional | | $162.18 | $162.18 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $234.42 / $302.00
| Professional | | $60.26 | $234.42 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $281.84 / $478.63
| Facility | | $234.42 | $281.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $229.09 / $363.08
| Professional | | $177.83 | $229.09 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $316.23 / $426.58
| Professional | | $288.40 | $316.23 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $323.59 / $478.63
| Professional | | $234.42 | $323.59 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $208.93 / $239.88
| Facility | | $131.83 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $158.49 / $239.88
| Professional | | $123.03 | $158.49 | $239.88 |