- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.70 / $328.65 / $8,500.00
| Facility | | $202.70 | $328.65 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.70 / $268.74 / $354.05
| Professional | | $202.70 | $268.74 | $354.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.13 / $549.04 / $841.08
| Professional | | $422.13 | $549.04 | $841.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.97 / $623.55 / $1,043.27
| Professional | | $292.97 | $623.55 | $1,043.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.70 / $328.65 / $608.10
| Facility | | $202.70 | $328.65 | $608.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.33 / $540.60 / $857.14
| Professional | | $297.33 | $540.60 | $857.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.33 / $602.91 / $857.14
| Professional | | $297.33 | $602.91 | $857.14 |