- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.78 / $186.78 / $8,500.00
| Facility | | $186.78 | $186.78 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.97 / $192.80 / $266.58
| Professional | | $172.97 | $192.80 | $266.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.78 / $376.03 / $515.61
| Facility | | $186.78 | $376.03 | $515.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.45 / $575.90 / $689.97
| Professional | | $286.45 | $575.90 | $689.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.14 / $514.21 / $682.60
| Professional | | $281.14 | $514.21 | $682.60 |