- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.43 / $189.43 / $8,500.00
| Facility | | $189.43 | $189.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.43 / $215.20 / $337.08
| Professional | | $189.43 | $215.20 | $337.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.43 / $373.60 / $512.12
| Facility | | $189.43 | $373.60 | $512.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.11 / $541.77 / $637.38
| Professional | | $285.11 | $541.77 | $637.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.95 / $507.51 / $637.27
| Professional | | $306.95 | $507.51 | $637.27 |