- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.88 / $132.84 / $2,000.00
| Facility | | $115.88 | $132.84 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.88 / $141.87 / $201.45
| Professional | | $115.88 | $141.87 | $201.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.71 / $291.86 / $344.84
| Professional | | $236.71 | $291.86 | $344.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $355.07 / $417.72 / $517.26
| Professional | 50 | $355.07 | $417.72 | $517.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.02 / $294.06 / $387.81
| Professional | | $174.02 | $294.06 | $387.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.88 / $194.57 / $233.48
| Facility | | $115.88 | $194.57 | $233.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.07 / $243.69 / $1,415.00
| Professional | | $142.07 | $243.69 | $1,415.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.07 / $232.47 / $286.70
| Professional | | $142.07 | $232.47 | $286.70 |