- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.86 / $1,319.09 / $8,500.00
| Facility | | $307.86 | $1,319.09 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.45 / $1,163.24 / $1,796.88
| Professional | | $306.45 | $1,163.24 | $1,796.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.80 / $1,751.46 / $2,753.87
| Professional | | $612.80 | $1,751.46 | $2,753.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.16 / $974.57 / $3,005.13
| Professional | | $379.16 | $974.57 | $3,005.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.86 / $1,319.09 / $2,242.44
| Facility | | $307.86 | $1,319.09 | $2,242.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.12 / $2,419.87 / $3,461.78
| Professional | | $1,337.12 | $2,419.87 | $3,461.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.83 / $2,444.06 / $3,461.78
| Professional | | $1,358.83 | $2,444.06 | $3,461.78 |