- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.13 / $604.13 / $8,500.00
| Facility | | $604.13 | $604.13 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.25 / $614.46 / $859.30
| Professional | | $547.25 | $614.46 | $859.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.20 / $1,347.75 / $1,592.38
| Professional | | $1,246.20 | $1,347.75 | $1,592.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.68 / $1,518.57 / $1,961.01
| Professional | | $937.68 | $1,518.57 | $1,961.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.13 / $783.19 / $1,027.02
| Facility | | $604.13 | $783.19 | $1,027.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.87 / $1,048.64 / $4,710.00
| Professional | | $630.87 | $1,048.64 | $4,710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.87 / $1,108.28 / $1,563.34
| Professional | | $630.87 | $1,108.28 | $1,563.34 |