- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.32 / $825.04 / $8,500.00
| Facility | | $261.32 | $825.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.32 / $734.44 / $1,392.29
| Professional | | $261.32 | $734.44 | $1,392.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.98 / $1,160.09 / $1,824.05
| Professional | | $504.98 | $1,160.09 | $1,824.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.29 / $836.46 / $2,489.51
| Professional | | $351.29 | $836.46 | $2,489.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.32 / $825.04 / $2,475.12
| Facility | | $261.32 | $825.04 | $2,475.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.20 / $1,440.52 / $2,163.71
| Professional | | $836.20 | $1,440.52 | $2,163.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.73 / $1,440.52 / $2,163.71
| Professional | | $503.73 | $1,440.52 | $2,163.71 |