- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.17 / $103.17 / $8,500.00
| Facility | | $103.17 | $103.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.17 / $103.17 / $157.26
| Professional | | $103.17 | $103.17 | $157.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.17 / $103.17 / $309.51
| Facility | | $103.17 | $103.17 | $309.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.15 / $292.16 / $381.18
| Professional | | $171.15 | $292.16 | $381.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.44 / $311.18 / $381.18
| Professional | | $167.44 | $311.18 | $381.18 |