- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.50 / $189.50 / $8,500.00
| Facility | | $189.50 | $189.50 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.26 / $189.50 / $202.77
| Professional | | $167.26 | $189.50 | $202.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.80 / $437.60 / $513.11
| Professional | | $397.80 | $437.60 | $513.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.25 / $502.12 / $668.83
| Professional | | $253.25 | $502.12 | $668.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.50 / $230.72 / $346.48
| Facility | | $189.50 | $230.72 | $346.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.52 / $352.17 / $494.36
| Professional | | $194.52 | $352.17 | $494.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.52 / $347.64 / $434.52
| Professional | | $194.52 | $347.64 | $434.52 |