- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.18 / $501.25 / $26,905.80
| Facility | | $136.18 | $501.25 | $26,905.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $457.94
| Professional | | $138.74 | $138.74 | $457.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.18 / $138.74 / $138.74
| Professional | | $136.18 | $138.74 | $138.74 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $147.51 / $150.52 / $282.63
| Professional | | $147.51 | $150.52 | $282.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |