- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.97 / $173.29 / $2,000.00
| Facility | | $129.97 | $173.29 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.81 / $159.78 / $186.88
| Professional | | $122.81 | $159.78 | $186.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.35 / $339.55 / $460.06
| Professional | | $262.35 | $339.55 | $460.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.60 / $325.97 / $545.37
| Professional | | $183.60 | $325.97 | $545.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.97 / $211.82 / $303.61
| Facility | | $129.97 | $211.82 | $303.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.70 / $324.64 / $962.16
| Professional | | $183.70 | $324.64 | $962.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.70 / $317.89 / $404.14
| Professional | | $183.70 | $317.89 | $404.14 |