- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.17 / $355.56 / $2,000.00
| Facility | | $167.17 | $355.56 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.37 / $268.85 / $355.56
| Professional | | $147.37 | $268.85 | $355.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.93 / $410.16 / $817.33
| Professional | | $316.93 | $410.16 | $817.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.51 / $492.63 / $1,016.90
| Professional | | $264.51 | $492.63 | $1,016.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.17 / $355.56 / $561.46
| Facility | | $167.17 | $355.56 | $561.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.45 / $604.08 / $1,237.61
| Professional | | $362.45 | $604.08 | $1,237.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.45 / $604.08 / $803.51
| Professional | | $362.45 | $604.08 | $803.51 |