- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.41 / $794.41 / $8,500.00
| Facility | | $794.41 | $794.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.41 / $794.41 / $5,294.00
| Professional | | $794.41 | $794.41 | $5,294.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.68 / $894.35 / $1,052.18
| Professional | | $846.68 | $894.35 | $1,052.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,369.88 / $13,369.88 / $16,712.34
| Professional | | $13,369.88 | $13,369.88 | $16,712.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.41 / $1,350.50 / $7,386.65
| Facility | | $794.41 | $1,350.50 | $7,386.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.50 / $2,081.92 / $2,934.70
| Professional | | $816.50 | $2,081.92 | $2,934.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.85 / $2,486.94 / $2,934.70
| Professional | | $1,207.85 | $2,486.94 | $2,934.70 |