- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.46 / $197.67 / $2,000.00
| Facility | | $177.46 | $197.67 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.13 / $182.34 / $203.68
| Professional | | $160.13 | $182.34 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.32 / $423.91 / $501.50
| Professional | | $360.32 | $423.91 | $501.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.77 / $459.93 / $650.54
| Professional | | $258.77 | $459.93 | $650.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.46 / $262.14 / $353.50
| Facility | | $177.46 | $262.14 | $353.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.02 / $367.42 / $1,358.96
| Professional | | $201.02 | $367.42 | $1,358.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.02 / $362.63 / $476.82
| Professional | | $201.02 | $362.63 | $476.82 |