- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.75 / $145.84 / $2,000.00
| Facility | | $144.75 | $145.84 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.97 / $145.84 / $155.82
| Professional | | $127.97 | $145.84 | $155.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.67 / $342.43 / $400.79
| Professional | | $306.67 | $342.43 | $400.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.88 / $387.35 / $512.25
| Professional | | $193.88 | $387.35 | $512.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.75 / $205.83 / $269.68
| Facility | | $144.75 | $205.83 | $269.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.85 / $267.54 / $1,126.40
| Professional | | $150.85 | $267.54 | $1,126.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.85 / $267.00 / $331.87
| Professional | | $150.85 | $267.00 | $331.87 |