- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.45 / $200.98 / $2,000.00
| Facility | | $102.45 | $200.98 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.55 / $200.98 / $251.48
| Professional | | $93.55 | $200.98 | $251.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.75 / $325.20 / $557.25
| Professional | | $209.75 | $325.20 | $557.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.52 / $283.39 / $567.35
| Professional | | $142.52 | $283.39 | $567.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.45 / $200.98 / $373.46
| Facility | | $102.45 | $200.98 | $373.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.39 / $349.80 / $1,626.16
| Professional | | $192.39 | $349.80 | $1,626.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.00 / $1,530.00 / $1,530.00
| Facility | | $1,530.00 | $1,530.00 | $1,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.39 / $314.82 / $523.11
| Professional | | $192.39 | $314.82 | $523.11 |