- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.94 / $194.20 / $2,000.00
| Facility | | $107.94 | $194.20 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.14 / $167.08 / $259.27
| Professional | | $98.14 | $167.08 | $259.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.93 / $305.02 / $522.67
| Professional | | $220.93 | $305.02 | $522.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.32 / $286.06 / $551.61
| Professional | | $144.32 | $286.06 | $551.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.94 / $194.20 / $353.11
| Facility | | $107.94 | $194.20 | $353.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.68 / $334.87 / $1,538.16
| Professional | | $194.68 | $334.87 | $1,538.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.00 / $125.00 / $125.00
| Facility | | $125.00 | $125.00 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.84 / $327.67 / $507.24
| Professional | | $187.84 | $327.67 | $507.24 |