- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.43 / $189.43 / $8,500.00
| Facility | | $189.43 | $189.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.55 / $189.43 / $291.33
| Professional | | $113.55 | $189.43 | $291.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.63 / $396.55 / $498.63
| Professional | | $392.63 | $396.55 | $498.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.78 / $189.43 / $609.48
| Facility | | $146.78 | $189.43 | $609.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.11 / $487.51 / $637.27
| Professional | | $285.11 | $487.51 | $637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.37 / $477.89 / $584.05
| Professional | | $281.37 | $477.89 | $584.05 |