- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.18 / $149.32 / $2,000.00
| Facility | | $108.18 | $149.32 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.58 / $143.10 / $219.95
| Professional | | $105.58 | $143.10 | $219.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.27 / $284.12 / $370.62
| Professional | | $220.27 | $284.12 | $370.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.83 / $275.47 / $421.69
| Professional | | $144.83 | $275.47 | $421.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.18 / $175.88 / $327.64
| Facility | | $108.18 | $175.88 | $327.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.02 / $286.06 / $1,090.08
| Professional | | $144.02 | $286.06 | $1,090.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.12 / $268.77 / $390.35
| Professional | | $132.12 | $268.77 | $390.35 |