- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.91 / $213.14 / $8,500.00
| Facility | | $122.91 | $213.14 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.91 / $213.14 / $350.07
| Professional | | $122.91 | $213.14 | $350.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.58 / $333.57 / $567.04
| Professional | | $246.58 | $333.57 | $567.04 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $369.87 / $478.67 / $825.23
| Professional | 50 | $369.87 | $478.67 | $825.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.86 / $378.92 / $705.71
| Professional | | $214.86 | $378.92 | $705.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.91 / $213.14 / $639.41
| Facility | | $122.91 | $213.14 | $639.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.59 / $389.32 / $556.40
| Professional | | $233.59 | $389.32 | $556.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.34 / $391.01 / $556.40
| Professional | | $218.34 | $391.01 | $556.40 |