- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.95 / $251.81 / $2,000.00
| Facility | | $100.95 | $251.81 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.70 / $190.92 / $275.01
| Professional | | $87.70 | $190.92 | $275.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.75 / $389.16 / $670.86
| Professional | | $209.75 | $389.16 | $670.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.62 / $346.22 / $708.01
| Professional | | $162.62 | $346.22 | $708.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.95 / $251.81 / $460.85
| Facility | | $100.95 | $251.81 | $460.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.15 / $450.46 / $1,025.65
| Professional | | $255.15 | $450.46 | $1,025.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.15 / $450.46 / $561.33
| Professional | | $255.15 | $450.46 | $561.33 |