- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.55 / $2,000.00 / $8,500.00
| Facility | | $205.55 | $2,000.00 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.33 / $1,157.70 / $2,778.38
| Professional | | $174.33 | $1,157.70 | $2,778.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.11 / $516.52 / $3,104.29
| Professional | | $399.11 | $516.52 | $3,104.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.08 / $2,043.32 / $4,273.30
| Professional | | $247.08 | $2,043.32 | $4,273.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.55 / $1,930.46 / $3,638.53
| Facility | | $205.55 | $1,930.46 | $3,638.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,459.21 / $4,844.47 / $5,633.37
| Professional | | $2,459.21 | $4,844.47 | $5,633.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.42 / $4,602.34 / $5,633.37
| Professional | | $2,170.42 | $4,602.34 | $5,633.37 |