- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.34 / $108.34 / $8,500.00
| Facility | | $108.34 | $108.34 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.50 / $108.34 / $108.34
| Professional | | $92.50 | $108.34 | $108.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.17 / $236.74 / $283.80
| Professional | | $216.17 | $236.74 | $283.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.63 / $241.80 / $312.24
| Professional | | $141.63 | $241.80 | $312.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.34 / $148.97 / $325.02
| Facility | | $108.34 | $148.97 | $325.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.37 / $198.75 / $276.75
| Professional | | $118.37 | $198.75 | $276.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.37 / $233.83 / $276.75
| Professional | | $118.37 | $233.83 | $276.75 |