- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.16 / $406.93 / $2,000.00
| Facility | | $161.16 | $406.93 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.94 / $389.17 / $470.55
| Professional | | $147.94 | $389.17 | $470.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.33 / $607.11 / $1,043.61
| Professional | | $312.33 | $607.11 | $1,043.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.13 / $479.97 / $1,091.33
| Professional | | $224.13 | $479.97 | $1,091.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.16 / $406.93 / $752.82
| Facility | | $161.16 | $406.93 | $752.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.84 / $746.51 / $3,110.96
| Professional | | $393.84 | $746.51 | $3,110.96 |
- 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
- $306.45 / $646.70 / $1,066.53
| Professional | | $306.45 | $646.70 | $1,066.53 |