- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.02 / $2,000.00 / $8,500.00
| Facility | | $168.02 | $2,000.00 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.83 / $445.50 / $3,249.37
| Professional | | $157.83 | $445.50 | $3,249.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.23 / $3,769.10 / $6,497.45
| Professional | | $343.23 | $3,769.10 | $6,497.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.68 / $556.41 / $8,241.74
| Professional | | $249.68 | $556.41 | $8,241.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.02 / $504.06 / $5,276.68
| Facility | | $168.02 | $504.06 | $5,276.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,750.76 / $6,402.71 / $9,034.12
| Professional | | $3,750.76 | $6,402.71 | $9,034.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,788.00 / $6,819.56 / $9,034.12
| Professional | | $3,788.00 | $6,819.56 | $9,034.12 |