- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.19 / $2,021.01 / $8,500.00
| Facility | | $788.19 | $2,021.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.19 / $1,712.12 / $2,144.64
| Professional | | $767.19 | $1,712.12 | $2,144.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.48 / $2,161.61 / $4,363.51
| Professional | | $1,523.48 | $2,161.61 | $4,363.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.85 / $2,503.73 / $4,700.39
| Professional | | $1,194.85 | $2,503.73 | $4,700.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.19 / $1,339.92 / $3,061.04
| Facility | | $788.19 | $1,339.92 | $3,061.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.78 / $4,153.95 / $7,351.00
| Professional | | $2,039.78 | $4,153.95 | $7,351.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.67 / $3,707.54 / $4,615.50
| Professional | | $1,676.67 | $3,707.54 | $4,615.50 |