- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.49 / $118.73 / $2,000.00
| Facility | | $102.49 | $118.73 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.52 / $103.81 / $181.57
| Professional | | $84.52 | $103.81 | $181.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.53 / $275.89 / $332.40
| Professional | | $225.53 | $275.89 | $332.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.59 / $270.89 / $399.80
| Professional | | $135.59 | $270.89 | $399.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.49 / $174.23 / $221.92
| Facility | | $102.49 | $174.23 | $221.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.23 / $217.81 / $817.04
| Professional | | $125.23 | $217.81 | $817.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.23 / $217.81 / $275.51
| Professional | | $125.23 | $217.81 | $275.51 |