- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.83 / $304.83 / $8,500.00
| Facility | | $304.83 | $304.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.83 / $304.83 / $307.10
| Professional | | $304.83 | $304.83 | $307.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.96 / $395.96 / $395.96
| Professional | | $395.96 | $395.96 | $395.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.38 / $304.83 / $914.52
| Facility | | $146.38 | $304.83 | $914.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.05 / $694.43 / $871.00
| Professional | | $479.05 | $694.43 | $871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.74 / $694.43 / $871.00
| Professional | | $505.74 | $694.43 | $871.00 |