- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.81 / $159.55 / $8,500.00
| Facility | | $136.81 | $159.55 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.13 / $159.55 / $241.22
| Professional | | $136.13 | $159.55 | $241.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.63 / $347.83 / $443.24
| Professional | | $290.63 | $347.83 | $443.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.93 / $361.19 / $545.37
| Professional | | $179.93 | $361.19 | $545.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.81 / $204.84 / $410.43
| Facility | | $136.81 | $204.84 | $410.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.30 / $270.04 / $415.53
| Professional | | $158.30 | $270.04 | $415.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.02 / $309.73 / $481.45
| Professional | | $162.02 | $309.73 | $481.45 |