- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $302.00
| Facility | | $204.17 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $234.42 / $645.65
| Professional | | $190.55 | $234.42 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $1,584.89
| Facility | | $457.09 | $457.09 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $245.47 / $416.87
| Professional | | $234.42 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $457.09
| Professional | | $275.42 | $275.42 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $316.23
| Professional | | $234.42 | $234.42 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $354.81 / $1,000.00
| Facility | | $223.87 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $223.87 / $2,238.72
| Professional | | $154.88 | $223.87 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $354.81 / $426.58
| Facility | | $263.03 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $223.87 / $316.23
| Professional | | $154.88 | $223.87 | $316.23 |