- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.04 / $344.03 / $5,000.00
| Facility | | $200.04 | $344.03 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.62 / $302.68 / $569.47
| Professional | | $194.62 | $302.68 | $569.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.23 / $506.32 / $892.22
| Professional | | $391.23 | $506.32 | $892.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.51 / $584.52 / $1,088.63
| Professional | | $303.51 | $584.52 | $1,088.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.04 / $344.03 / $2,952.24
| Facility | | $200.04 | $344.03 | $2,952.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.55 / $582.82 / $897.30
| Professional | | $320.55 | $582.82 | $897.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.69 / $582.82 / $897.30
| Professional | | $349.69 | $582.82 | $897.30 |