- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.46 / $122.84 / $8,500.00
| Facility | | $52.46 | $122.84 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.49 / $86.85 / $273.60
| Professional | | $43.49 | $86.85 | $273.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.26 / $176.62 / $277.70
| Professional | | $101.26 | $176.62 | $277.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.83 / $202.77 / $377.65
| Professional | | $83.83 | $202.77 | $377.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.46 / $122.84 / $208.83
| Facility | | $52.46 | $122.84 | $208.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.38 / $225.35 / $903.20
| Professional | | $122.38 | $225.35 | $903.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.38 / $149.41 / $265.13
| Professional | | $122.38 | $149.41 | $265.13 |