- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.03 / $958.03 / $8,500.00
| Facility | | $958.03 | $958.03 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.79 / $917.72 / $1,038.93
| Professional | | $916.79 | $917.72 | $1,038.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.49 / $2,123.64 / $2,490.08
| Professional | | $1,930.49 | $2,123.64 | $2,490.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.71 / $2,227.90 / $2,967.56
| Professional | | $1,263.71 | $2,227.90 | $2,967.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.03 / $1,319.31 / $2,048.17
| Facility | | $958.03 | $1,319.31 | $2,048.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.58 / $1,757.51 / $2,453.50
| Professional | | $1,037.58 | $1,757.51 | $2,453.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.58 / $1,757.51 / $2,453.50
| Professional | | $1,037.58 | $1,757.51 | $2,453.50 |