- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.69 / $176.69 / $8,500.00
| Facility | | $176.69 | $176.69 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.59 / $241.81 / $265.89
| Professional | | $172.59 | $241.81 | $265.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.76 / $176.69 / $251.46
| Facility | | $50.76 | $176.69 | $251.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.98 / $463.05 / $718.67
| Professional | | $265.98 | $463.05 | $718.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.98 / $470.78 / $652.69
| Professional | | $265.98 | $470.78 | $652.69 |