- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.69 / $2,500.00 / $3,291.72
| Facility | | $157.69 | $2,500.00 | $3,291.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.56 / $237.44 / $280.70
| Professional | | $155.56 | $237.44 | $280.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.27 / $409.31 / $622.35
| Professional | | $316.27 | $409.31 | $622.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.02 / $386.51 / $773.22
| Professional | | $231.02 | $386.51 | $773.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.69 / $251.16 / $473.07
| Facility | | $157.69 | $251.16 | $473.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.04 / $473.61 / $654.92
| Professional | | $258.04 | $473.61 | $654.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.44 / $473.61 / $654.92
| Professional | | $277.44 | $473.61 | $654.92 |