- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.08 / $743.40 / $8,500.00
| Facility | | $176.08 | $743.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.04 / $264.91 / $757.87
| Professional | | $163.04 | $264.91 | $757.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.92 / $1,043.50 / $1,798.86
| Professional | | $341.92 | $1,043.50 | $1,798.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.67 / $545.44 / $2,251.10
| Professional | | $248.67 | $545.44 | $2,251.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.08 / $743.40 / $1,955.00
| Facility | | $176.08 | $743.40 | $1,955.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.75 / $1,334.58 / $1,951.98
| Professional | | $800.75 | $1,334.58 | $1,951.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.02 / $1,363.77 / $1,951.98
| Professional | | $751.02 | $1,363.77 | $1,951.98 |