- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $151.53 / $2,000.00
| Facility | | $112.20 | $151.53 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.62 / $133.81 / $162.91
| Professional | | $103.62 | $133.81 | $162.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.45 / $299.54 / $403.69
| Professional | | $231.45 | $299.54 | $403.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.41 / $286.06 / $493.01
| Professional | | $161.41 | $286.06 | $493.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $186.34 / $270.64
| Facility | | $112.20 | $186.34 | $270.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.16 / $277.98 / $837.28
| Professional | | $159.16 | $277.98 | $837.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.16 / $277.98 / $350.15
| Professional | | $159.16 | $277.98 | $350.15 |