- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.98 / $1,943.21 / $8,500.00
| Facility | | $176.98 | $1,943.21 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.46 / $984.90 / $1,943.21
| Professional | | $163.46 | $984.90 | $1,943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.20 / $2,597.67 / $4,433.22
| Professional | | $345.20 | $2,597.67 | $4,433.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.16 / $562.77 / $5,660.46
| Professional | | $248.16 | $562.77 | $5,660.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.98 / $1,943.21 / $3,303.46
| Facility | | $176.98 | $1,943.21 | $3,303.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.64 / $3,689.89 / $5,116.56
| Professional | | $1,950.64 | $3,689.89 | $5,116.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.23 / $3,930.12 / $5,116.56
| Professional | | $1,928.23 | $3,930.12 | $5,116.56 |