- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.40 / $177.57 / $8,500.00
| Facility | | $140.40 | $177.57 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $177.57 / $236.66
| Professional | | $135.44 | $177.57 | $236.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.29 / $375.87 / $514.22
| Professional | | $291.29 | $375.87 | $514.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.65 / $376.17 / $630.82
| Professional | | $187.65 | $376.17 | $630.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.40 / $207.21 / $421.20
| Facility | | $140.40 | $207.21 | $421.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.72 / $286.62 / $462.32
| Professional | | $165.72 | $286.62 | $462.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.90 / $325.75 / $462.32
| Professional | | $165.90 | $325.75 | $462.32 |