- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.18 / $216.78 / $2,000.00
| Facility | | $152.18 | $216.78 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.77 / $201.22 / $303.02
| Professional | | $142.77 | $201.22 | $303.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.06 / $397.39 / $550.71
| Professional | | $307.06 | $397.39 | $550.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.30 / $395.41 / $585.04
| Professional | | $188.30 | $395.41 | $585.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.18 / $238.70 / $450.00
| Facility | | $152.18 | $238.70 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.51 / $388.86 / $1,131.20
| Professional | | $211.51 | $388.86 | $1,131.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Facility | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.18 / $367.20 / $567.27
| Professional | | $206.18 | $367.20 | $567.27 |