- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.92 / $140.85 / $8,500.00
| Facility | | $71.92 | $140.85 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.31 / $113.71 / $161.66
| Professional | | $67.31 | $113.71 | $161.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.71 / $308.81 / $402.80
| Professional | | $140.71 | $308.81 | $402.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.40 / $216.25 / $503.18
| Professional | | $103.40 | $216.25 | $503.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.92 / $140.85 / $239.45
| Facility | | $71.92 | $140.85 | $239.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.52 / $219.06 / $368.14
| Professional | | $128.52 | $219.06 | $368.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.94 / $285.45 / $443.73
| Professional | | $129.94 | $285.45 | $443.73 |