- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.06 / $195.28 / $8,500.00
| Facility | | $140.06 | $195.28 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.71 / $184.84 / $195.28
| Professional | | $127.71 | $184.84 | $195.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.76 / $362.15 / $495.24
| Professional | | $280.76 | $362.15 | $495.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.31 / $371.36 / $621.32
| Professional | | $207.31 | $371.36 | $621.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.06 / $200.63 / $420.18
| Facility | | $140.06 | $200.63 | $420.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.97 / $358.24 / $509.22
| Professional | | $203.97 | $358.24 | $509.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.70 / $416.62 / $509.22
| Professional | | $207.70 | $416.62 | $509.22 |