- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.86 / $290.74 / $8,500.00
| Facility | | $191.86 | $290.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.82 / $276.30 / $319.87
| Professional | | $176.82 | $276.30 | $319.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.30 / $467.31 / $687.56
| Professional | | $362.30 | $467.31 | $687.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.06 / $493.76 / $870.27
| Professional | | $225.06 | $493.76 | $870.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.86 / $290.74 / $575.58
| Facility | | $191.86 | $290.74 | $575.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.86 / $552.83 / $761.03
| Professional | | $315.86 | $552.83 | $761.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.57 / $588.82 / $761.03
| Professional | | $295.57 | $588.82 | $761.03 |