- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.06 / $981.06 / $8,500.00
| Facility | | $981.06 | $981.06 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.53 / $983.95 / $1,023.12
| Professional | | $901.53 | $983.95 | $1,023.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.04 / $2,185.84 / $2,563.02
| Professional | | $1,987.04 | $2,185.84 | $2,563.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.96 / $2,460.81 / $3,277.81
| Professional | | $1,445.96 | $2,460.81 | $3,277.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.06 / $1,416.12 / $2,185.16
| Facility | | $981.06 | $1,416.12 | $2,185.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.53 / $1,799.75 / $2,550.11
| Professional | | $1,019.53 | $1,799.75 | $2,550.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.53 / $1,745.05 / $2,117.42
| Professional | | $1,019.53 | $1,745.05 | $2,117.42 |