- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.48 / $101.48 / $8,500.00
| Facility | | $101.48 | $101.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.34 / $101.48 / $101.48
| Professional | | $97.34 | $101.48 | $101.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.31 / $230.40 / $276.20
| Professional | | $212.31 | $230.40 | $276.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.94 / $236.89 / $305.91
| Professional | | $129.94 | $236.89 | $305.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.48 / $145.19 / $304.44
| Facility | | $101.48 | $145.19 | $304.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.91 / $168.18 / $259.20
| Professional | | $100.91 | $168.18 | $259.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.25 / $170.89 / $259.20
| Professional | | $108.25 | $170.89 | $259.20 |