- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.53 / $103.53 / $103.53
| Facility | | $103.53 | $103.53 | $103.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.53 / $118.32 / $33,907.19
| Professional | | $103.53 | $118.32 | $33,907.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $482.61
| Professional | | $410.22 | $410.22 | $482.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.88 / $161.40 / $1,226.58
| Facility | | $113.88 | $161.40 | $1,226.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.04 / $200.08 / $376.59
| Professional | | $100.04 | $200.08 | $376.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.04 / $150.06 / $358.66
| Professional | | $100.04 | $150.06 | $358.66 |