- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.78 / $163.26 / $8,500.00
| Facility | | $34.78 | $163.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.78 / $163.26 / $250.05
| Professional | | $34.78 | $163.26 | $250.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.09 / $205.16 / $322.57
| Professional | | $65.09 | $205.16 | $322.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $100.21 / $376.35
| Professional | | $47.92 | $100.21 | $376.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.78 / $163.26 / $277.54
| Facility | | $34.78 | $163.26 | $277.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.93 / $314.64 / $428.78
| Professional | | $164.93 | $314.64 | $428.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.33 / $343.05 / $428.78
| Professional | | $184.33 | $343.05 | $428.78 |