- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.86 / $112.72 / $8,500.00
| Facility | | $57.86 | $112.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.86 / $108.15 / $129.37
| Professional | | $57.86 | $108.15 | $129.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.33 / $161.37 / $274.86
| Professional | | $120.33 | $161.37 | $274.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.28 / $164.43 / $343.89
| Professional | | $89.28 | $164.43 | $343.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.86 / $112.72 / $191.62
| Facility | | $57.86 | $112.72 | $191.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.76 / $211.62 / $295.08
| Professional | | $114.76 | $211.62 | $295.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.76 / $211.62 / $295.08
| Professional | | $114.76 | $211.62 | $295.08 |