- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.27 / $154.27 / $8,500.00
| Facility | | $154.27 | $154.27 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.27 / $154.27 / $225.59
| Professional | | $154.27 | $154.27 | $225.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.27 / $262.26 / $462.81
| Facility | | $154.27 | $262.26 | $462.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.08 / $430.62 / $593.00
| Professional | | $241.08 | $430.62 | $593.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.80 / $458.66 / $593.00
| Professional | | $265.80 | $458.66 | $593.00 |