- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.68 / $124.68 / $8,500.00
| Facility | | $124.68 | $124.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.09 / $122.57 / $134.07
| Professional | | $114.09 | $122.57 | $134.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.57 / $292.83 / $390.05
| Professional | | $146.57 | $292.83 | $390.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.68 / $193.62 / $318.24
| Facility | | $124.68 | $193.62 | $318.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.37 / $230.33 / $322.39
| Professional | | $131.37 | $230.33 | $322.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.37 / $214.57 / $269.10
| Professional | | $131.37 | $214.57 | $269.10 |