- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.72 / $236.72 / $1,400.00
| Facility | | $236.72 | $236.72 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.34 / $259.45 / $1,632.38
| Professional | | $221.34 | $259.45 | $1,632.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.75 / $247.85 / $317.83
| Facility | | $181.75 | $247.85 | $317.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.28 / $282.52 / $72,899.27
| Professional | | $198.28 | $282.52 | $72,899.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.22 / $297.22 / $297.22
| Facility | | $297.22 | $297.22 | $297.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.01 / $326.70 / $577.50
| Professional | | $224.01 | $326.70 | $577.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.75 / $244.57 / $460.30
| Professional | | $165.75 | $244.57 | $460.30 |