- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.58 / $755.53 / $8,500.00
| Facility | | $162.58 | $755.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.72 / $755.53 / $1,024.01
| Professional | | $151.72 | $755.53 | $1,024.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.25 / $1,090.09 / $1,838.73
| Professional | | $318.25 | $1,090.09 | $1,838.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.53 / $486.30 / $2,307.01
| Professional | | $232.53 | $486.30 | $2,307.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.58 / $755.53 / $1,284.40
| Facility | | $162.58 | $755.53 | $1,284.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.11 / $1,386.02 / $1,985.37
| Professional | | $766.11 | $1,386.02 | $1,985.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.11 / $1,392.92 / $1,985.37
| Professional | | $766.11 | $1,392.92 | $1,985.37 |