- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $8,980.00
| Facility | | $246.23 | $246.23 | $8,980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.22 / $246.23 / $275.31
| Professional | | $246.22 | $246.23 | $275.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $125.00 / $181.88
| Professional | | $50.00 | $125.00 | $181.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.36 / $198.02 / $451.85
| Facility | | $35.36 | $198.02 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $258.54 / $512.16
| Facility | | $246.23 | $258.54 | $512.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.64 / $306.64 / $306.64
| Professional | | $306.64 | $306.64 | $306.64 |