- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.69 / $503.25 / $2,000.00
| Facility | | $103.69 | $503.25 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.73 / $127.26 / $204.50
| Professional | | $82.73 | $127.26 | $204.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.41 / $271.39 / $351.97
| Professional | | $210.41 | $271.39 | $351.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.61 / $281.58 / $400.95
| Professional | | $198.61 | $281.58 | $400.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.69 / $154.41 / $311.07
| Facility | | $103.69 | $154.41 | $311.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.55 / $280.92 / $1,134.88
| Professional | | $155.55 | $280.92 | $1,134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.04 / $236.82 / $330.50
| Professional | | $153.04 | $236.82 | $330.50 |