- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.22 / $126.07 / $8,500.00
| Facility | | $71.22 | $126.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.17 / $113.34 / $139.02
| Professional | | $65.17 | $113.34 | $139.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.76 / $176.41 / $283.12
| Professional | | $136.76 | $176.41 | $283.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.30 / $212.03 / $382.92
| Professional | | $120.30 | $212.03 | $382.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.22 / $126.07 / $214.32
| Facility | | $71.22 | $126.07 | $214.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.12 / $233.41 / $913.76
| Professional | | $128.12 | $233.41 | $913.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.12 / $220.44 / $272.10
| Professional | | $128.12 | $220.44 | $272.10 |