- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.52 / $202.31 / $2,000.00
| Facility | | $126.52 | $202.31 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.52 / $311.73 / $751.52
| Professional | | $126.52 | $311.73 | $751.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.94 / $331.16 / $518.46
| Professional | | $243.94 | $331.16 | $518.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.56 / $316.45 / $610.21
| Professional | | $178.56 | $316.45 | $610.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.52 / $205.58 / $379.56
| Facility | | $126.52 | $205.58 | $379.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.01 / $362.33 / $921.84
| Professional | | $207.01 | $362.33 | $921.84 |
- 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
- $186.64 / $347.33 / $527.66
| Professional | | $186.64 | $347.33 | $527.66 |