- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.61 / $740.61 / $8,500.00
| Facility | | $740.61 | $740.61 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.50 / $757.12 / $781.03
| Professional | | $725.50 | $757.12 | $781.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.79 / $1,652.04 / $1,937.11
| Professional | | $1,501.79 | $1,652.04 | $1,937.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.48 / $1,848.98 / $2,462.85
| Professional | | $925.48 | $1,848.98 | $2,462.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.61 / $1,022.35 / $1,282.85
| Facility | | $740.61 | $1,022.35 | $1,282.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.79 / $1,462.60 / $1,920.98
| Professional | | $769.79 | $1,462.60 | $1,920.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.79 / $1,400.38 / $1,704.69
| Professional | | $769.79 | $1,400.38 | $1,704.69 |