- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.87 / $242.48 / $2,000.00
| Facility | | $155.87 | $242.48 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.85 / $215.49 / $254.42
| Professional | | $145.85 | $215.49 | $254.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.56 / $413.56 / $636.16
| Professional | | $319.56 | $413.56 | $636.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.54 / $488.41 / $686.55
| Professional | | $233.54 | $488.41 | $686.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.87 / $242.48 / $447.21
| Facility | | $155.87 | $242.48 | $447.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.10 / $459.88 / $1,168.08
| Professional | | $250.10 | $459.88 | $1,168.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.10 / $442.68 / $550.22
| Professional | | $250.10 | $442.68 | $550.22 |