- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.81 / $251.03 / $2,000.00
| Facility | | $160.81 | $251.03 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.08 / $205.62 / $261.51
| Professional | | $146.08 | $205.62 | $261.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.25 / $451.54 / $632.70
| Professional | | $318.25 | $451.54 | $632.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.16 / $465.31 / $778.50
| Professional | | $248.16 | $465.31 | $778.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.81 / $252.37 / $429.57
| Facility | | $160.81 | $252.37 | $429.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.24 / $460.51 / $1,214.24
| Professional | | $256.24 | $460.51 | $1,214.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.24 / $434.74 / $541.79
| Professional | | $256.24 | $434.74 | $541.79 |