- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.87 / $144.01 / $8,500.00
| Facility | | $102.87 | $144.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.17 / $157.13 / $223.81
| Professional | | $96.17 | $157.13 | $223.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.83 / $262.92 / $328.77
| Professional | | $203.83 | $262.92 | $328.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.37 / $254.91 / $428.28
| Professional | | $172.37 | $254.91 | $428.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.87 / $144.01 / $312.89
| Facility | | $102.87 | $144.01 | $312.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.77 / $373.83 / $1,303.72
| Professional | | $149.77 | $373.83 | $1,303.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.62 / $223.16 / $401.56
| Professional | | $148.62 | $223.16 | $401.56 |