- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.86 / $207.06 / $8,500.00
| Facility | | $125.86 | $207.06 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.86 / $207.06 / $216.42
| Professional | | $125.86 | $207.06 | $216.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.08 / $333.64 / $526.61
| Professional | | $257.08 | $333.64 | $526.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.51 / $343.28 / $657.19
| Professional | | $160.51 | $343.28 | $657.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.86 / $207.06 / $621.17
| Facility | | $125.86 | $207.06 | $621.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.40 / $393.44 / $542.53
| Professional | | $210.40 | $393.44 | $542.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.48 / $397.13 / $542.53
| Professional | | $230.48 | $397.13 | $542.53 |