- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.75 / $169.60 / $2,000.00
| Facility | | $114.75 | $169.60 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.27 / $144.12 / $210.54
| Professional | | $107.27 | $144.12 | $210.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.13 / $297.83 / $444.31
| Professional | | $230.13 | $297.83 | $444.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.93 / $290.52 / $554.10
| Professional | | $163.93 | $290.52 | $554.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.75 / $189.34 / $301.41
| Facility | | $114.75 | $189.34 | $301.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.48 / $311.13 / $845.68
| Professional | | $176.48 | $311.13 | $845.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.48 / $311.13 / $388.26
| Professional | | $176.48 | $311.13 | $388.26 |