- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.47 / $286.67 / $8,500.00
| Facility | | $170.47 | $286.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.53 / $220.89 / $302.64
| Professional | | $151.53 | $220.89 | $302.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.46 / $497.25 / $759.50
| Professional | | $350.46 | $497.25 | $759.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.63 / $520.52 / $969.43
| Professional | | $225.63 | $520.52 | $969.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.47 / $286.67 / $531.47
| Facility | | $170.47 | $286.67 | $531.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.58 / $453.20 / $1,277.83
| Professional | | $294.58 | $453.20 | $1,277.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.85 / $453.20 / $648.66
| Professional | | $294.85 | $453.20 | $648.66 |