- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.83 / $1,957.13 / $8,500.00
| Facility | | $368.83 | $1,957.13 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.83 / $1,643.84 / $2,089.41
| Professional | | $368.83 | $1,643.84 | $2,089.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.49 / $915.62 / $3,986.14
| Professional | | $707.49 | $915.62 | $3,986.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.80 / $1,059.08 / $5,467.42
| Professional | | $450.80 | $1,059.08 | $5,467.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.83 / $1,957.13 / $3,327.12
| Facility | | $368.83 | $1,957.13 | $3,327.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.74 / $3,564.98 / $5,141.68
| Professional | | $1,960.74 | $3,564.98 | $5,141.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.04 / $3,564.98 / $5,141.68
| Professional | | $693.04 | $3,564.98 | $5,141.68 |