- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.71 / $265.74 / $3,680.00
| Facility | | $149.71 | $265.74 | $3,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.96 / $124.76 / $3,680.00
| Professional | | $119.96 | $124.76 | $3,680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.98 / $159.94 / $383.88
| Facility | | $51.98 | $159.94 | $383.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.64 / $82.85 / $117.40
| Professional | | $9.64 | $82.85 | $117.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.97 / $187.15 / $259.93
| Facility | | $103.97 | $187.15 | $259.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.79 / $183.79 / $229.73
| Professional | | $183.79 | $183.79 | $229.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.94 / $159.94 / $167.95
| Professional | | $159.94 | $159.94 | $167.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.18 / $67.18 / $159.94
| Professional | | $67.18 | $67.18 | $159.94 |