- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.74 / $3,121.23 / $11,757.60
| Facility | | $138.74 | $3,121.23 | $11,757.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $147.13
| Professional | | $138.74 | $138.74 | $147.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Facility | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.88 / $130.88 / $196.33
| Facility | | $130.88 | $130.88 | $196.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.18 / $147.06 / $247.06
| Facility | | $136.18 | $147.06 | $247.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.22 / $152.61 / $197.01
| Professional | | $151.22 | $152.61 | $197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |