- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.04 / $329.04 / $8,500.00
| Facility | | $329.04 | $329.04 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.04 / $843.14 / $25,364.80
| Professional | | $329.04 | $843.14 | $25,364.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.04 / $807.85 / $1,107.63
| Facility | | $329.04 | $807.85 | $1,107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.89 / $615.35 / $1,342.49
| Professional | | $172.89 | $615.35 | $1,342.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.94 / $495.15 / $1,215.58
| Professional | | $195.94 | $495.15 | $1,215.58 |