- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.86 / $364.05 / $2,000.00
| Facility | | $256.86 | $364.05 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.54 / $295.57 / $429.59
| Professional | | $227.54 | $295.57 | $429.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.34 / $680.19 / $936.69
| Professional | | $527.34 | $680.19 | $936.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.51 / $701.12 / $994.07
| Professional | | $374.51 | $701.12 | $994.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.86 / $447.88 / $647.66
| Facility | | $256.86 | $447.88 | $647.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.53 / $667.85 / $1,944.88
| Professional | | $373.53 | $667.85 | $1,944.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.53 / $625.37 / $821.77
| Professional | | $373.53 | $625.37 | $821.77 |