- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.78 / $236.86 / $2,000.00
| Facility | | $235.78 | $236.86 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.55 / $236.86 / $251.75
| Professional | | $207.55 | $236.86 | $251.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.03 / $552.92 / $648.41
| Professional | | $501.03 | $552.92 | $648.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.58 / $624.49 / $824.25
| Professional | | $277.58 | $624.49 | $824.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.78 / $308.10 / $433.73
| Facility | | $235.78 | $308.10 | $433.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.41 / $434.52 / $1,834.32
| Professional | | $245.41 | $434.52 | $1,834.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.41 / $434.38 / $540.20
| Professional | | $245.41 | $434.38 | $540.20 |