- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.33 / $226.81 / $2,000.00
| Facility | | $137.33 | $226.81 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.55 / $164.52 / $264.70
| Professional | | $135.55 | $164.52 | $264.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.95 / $322.83 / $379.82
| Professional | | $266.95 | $322.83 | $379.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.91 / $309.11 / $407.18
| Professional | | $174.91 | $309.11 | $407.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.33 / $230.72 / $1,316.98
| Facility | | $137.33 | $230.72 | $1,316.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.70 / $306.30 / $430.89
| Professional | | $170.70 | $306.30 | $430.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.43 / $326.24 / $430.89
| Professional | | $179.43 | $326.24 | $430.89 |