- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $904.40 / $904.40 / $8,500.00
| Facility | | $904.40 | $904.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.30 / $897.64 / $1,260.50
| Professional | | $803.30 | $897.64 | $1,260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.23 / $1,972.87 / $2,362.06
| Professional | | $1,825.23 | $1,972.87 | $2,362.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.43 / $2,214.55 / $2,859.77
| Professional | | $1,367.43 | $2,214.55 | $2,859.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $904.40 / $1,143.52 / $1,537.48
| Facility | | $904.40 | $1,143.52 | $1,537.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.64 / $1,581.34 / $6,896.16
| Professional | | $941.64 | $1,581.34 | $6,896.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.24 / $1,469.58 / $2,342.15
| Professional | | $889.24 | $1,469.58 | $2,342.15 |