- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.97 / $286.79 / $8,500.00
| Facility | | $214.97 | $286.79 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.82 / $263.50 / $342.93
| Professional | | $191.82 | $263.50 | $342.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.06 / $519.90 / $670.22
| Professional | | $403.06 | $519.90 | $670.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.89 / $534.55 / $862.89
| Professional | | $267.89 | $534.55 | $862.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.97 / $292.04 / $860.37
| Facility | | $214.97 | $292.04 | $860.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.01 / $606.12 / $750.96
| Professional | | $339.01 | $606.12 | $750.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.88 / $605.03 / $750.96
| Professional | | $290.88 | $605.03 | $750.96 |