- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.48 / $181.74 / $8,500.00
| Facility | | $108.48 | $181.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.51 / $148.19 / $181.74
| Professional | | $96.51 | $148.19 | $181.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.75 / $270.55 / $400.70
| Professional | | $209.75 | $270.55 | $400.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.36 / $318.57 / $452.34
| Professional | | $197.36 | $318.57 | $452.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.48 / $181.74 / $325.44
| Facility | | $108.48 | $181.74 | $325.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.94 / $333.40 / $1,925.20
| Professional | | $186.94 | $333.40 | $1,925.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.38 / $273.32 / $473.79
| Professional | | $183.38 | $273.32 | $473.79 |