- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.56 / $133.93 / $2,000.00
| Facility | | $98.56 | $133.93 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.64 / $115.87 / $158.38
| Professional | | $89.64 | $115.87 | $158.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.58 / $256.99 / $342.35
| Professional | | $198.58 | $256.99 | $342.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.34 / $256.61 / $363.84
| Professional | | $141.34 | $256.61 | $363.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.56 / $140.21 / $237.22
| Facility | | $98.56 | $140.21 | $237.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $254.34 / $730.48
| Professional | | $138.94 | $254.34 | $730.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $245.92 / $348.31
| Professional | | $138.94 | $245.92 | $348.31 |