- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.78 / $143.47 / $8,500.00
| Facility | | $103.78 | $143.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.87 / $123.82 / $143.47
| Professional | | $95.87 | $123.82 | $143.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.21 / $260.39 / $340.36
| Professional | | $201.21 | $260.39 | $340.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.69 / $255.79 / $377.05
| Professional | | $163.69 | $255.79 | $377.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.78 / $143.47 / $311.33
| Facility | | $103.78 | $143.47 | $311.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.58 / $230.93 / $1,072.00
| Professional | | $147.58 | $230.93 | $1,072.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.19 / $213.84 / $309.64
| Professional | | $138.19 | $213.84 | $309.64 |