- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.60 / $213.36 / $8,500.00
| Facility | | $133.60 | $213.36 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $192.36 / $248.99
| Professional | | $132.00 | $192.36 | $248.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.56 / $350.27 / $538.99
| Professional | | $271.56 | $350.27 | $538.99 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $407.34 / $527.16 / $782.63
| Professional | 50 | $407.34 | $527.16 | $782.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.66 / $362.50 / $675.12
| Professional | | $167.66 | $362.50 | $675.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.60 / $213.36 / $400.80
| Facility | | $133.60 | $213.36 | $400.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $412.75 / $558.54
| Professional | | $217.26 | $412.75 | $558.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.79 / $439.62 / $558.54
| Professional | | $241.79 | $439.62 | $558.54 |