- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.46 / $245.32 / $8,500.00
| Facility | | $107.46 | $245.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.46 / $245.32 / $255.09
| Professional | | $107.46 | $245.32 | $255.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.67 / $279.11 / $537.62
| Professional | | $215.67 | $279.11 | $537.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.29 / $310.13 / $598.95
| Professional | | $148.29 | $310.13 | $598.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.46 / $245.32 / $417.04
| Facility | | $107.46 | $245.32 | $417.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.07 / $421.22 / $638.72
| Professional | | $177.07 | $421.22 | $638.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.73 / $433.86 / $638.72
| Professional | | $252.73 | $433.86 | $638.72 |