- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $263.03 / $346.74
| Professional | | $177.83 | $263.03 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $295.12 / $316.23
| Facility | | $281.84 | $295.12 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $645.65
| Professional | | $263.03 | $263.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $309.03 / $1,000.00
| Facility | | $134.90 | $309.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $223.87 / $3,090.30
| Professional | | $138.04 | $223.87 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $331.13 / $346.74
| Facility | | $281.84 | $331.13 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $208.93 / $316.23
| Professional | | $138.04 | $208.93 | $316.23 |