- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.91 / $945.58 / $2,000.00
| Facility | | $143.91 | $945.58 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.35 / $138.94 / $150.88
| Professional | | $124.35 | $138.94 | $150.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.70 / $313.20 / $367.24
| Professional | | $284.70 | $313.20 | $367.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.96 / $337.56 / $449.63
| Professional | | $168.96 | $337.56 | $449.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.91 / $178.72 / $244.65
| Facility | | $143.91 | $178.72 | $244.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.02 / $264.00 / $370.65
| Professional | | $153.02 | $264.00 | $370.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.02 / $270.85 / $350.73
| Professional | | $153.02 | $270.85 | $350.73 |