- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.57 / $309.70 / $8,500.00
| Facility | | $124.57 | $309.70 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $309.70 / $345.78
| Professional | | $124.57 | $309.70 | $345.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.43 / $331.87 / $755.67
| Professional | | $256.43 | $331.87 | $755.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.30 / $375.78 / $943.06
| Professional | | $181.30 | $375.78 | $943.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.57 / $309.70 / $526.49
| Facility | | $124.57 | $309.70 | $526.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.98 / $569.16 / $812.30
| Professional | | $313.98 | $569.16 | $812.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.08 / $568.14 / $812.30
| Professional | | $262.08 | $568.14 | $812.30 |