- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.51 / $174.51 / $8,500.00
| Facility | | $174.51 | $174.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.09 / $241.12 / $268.06
| Professional | | $174.09 | $241.12 | $268.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.51 / $308.50 / $422.87
| Facility | | $174.51 | $308.50 | $422.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.83 / $469.86 / $670.78
| Professional | | $272.83 | $469.86 | $670.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.83 / $475.63 / $559.58
| Professional | | $272.83 | $475.63 | $559.58 |