- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.99 / $125.99 / $8,500.00
| Facility | | $125.99 | $125.99 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.43 / $125.99 / $125.99
| Professional | | $111.43 | $125.99 | $125.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.26 / $262.82 / $315.06
| Professional | | $241.26 | $262.82 | $315.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.50 / $292.44 / $377.65
| Professional | | $150.50 | $292.44 | $377.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.99 / $175.38 / $377.97
| Facility | | $125.99 | $175.38 | $377.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.90 / $249.68 / $326.33
| Professional | | $132.90 | $249.68 | $326.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.90 / $265.94 / $326.33
| Professional | | $132.90 | $265.94 | $326.33 |