- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.51 / $106.51 / $8,500.00
| Facility | | $106.51 | $106.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.48 / $106.51 / $106.51
| Professional | | $102.48 | $106.51 | $106.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.24 / $243.08 / $291.39
| Professional | | $223.24 | $243.08 | $291.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.49 / $249.15 / $321.74
| Professional | | $137.49 | $249.15 | $321.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.51 / $153.36 / $319.52
| Facility | | $106.51 | $153.36 | $319.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.29 / $200.88 / $271.88
| Professional | | $117.29 | $200.88 | $271.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.38 / $241.82 / $284.01
| Professional | | $128.38 | $241.82 | $284.01 |