- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.40 / $182.40 / $8,500.00
| Facility | | $182.40 | $182.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.40 / $182.40 / $252.12
| Professional | | $182.40 | $182.40 | $252.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.40 / $182.40 / $547.20
| Facility | | $182.40 | $182.40 | $547.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.33 / $509.17 / $701.12
| Professional | | $314.33 | $509.17 | $701.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.27 / $542.32 / $701.12
| Professional | | $298.27 | $542.32 | $701.12 |