- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.92 / $237.04 / $1,600.00
| Facility | | $95.92 | $237.04 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.90 / $114.99 / $274.50
| Professional | | $86.90 | $114.99 | $274.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.78 / $116.06 / $126.45
| Facility | | $104.78 | $116.06 | $126.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.40 / $112.40 / $112.40
| Professional | | $112.40 | $112.40 | $112.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.01 / $168.01 / $168.01
| Facility | | $168.01 | $168.01 | $168.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.41 / $285.55 / $674.08
| Professional | | $112.41 | $285.55 | $674.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.45 / $1,030.45 / $1,030.45
| Facility | | $1,030.45 | $1,030.45 | $1,030.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.00 / $690.00 / $690.00
| Facility | | $690.00 | $690.00 | $690.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.90 / $316.24 / $509.33
| Professional | | $201.90 | $316.24 | $509.33 |