- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.31 / $944.31 / $8,500.00
| Facility | | $944.31 | $944.31 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.71 / $944.31 / $987.79
| Professional | | $841.71 | $944.31 | $987.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.71 / $2,106.27 / $2,469.73
| Professional | | $1,914.71 | $2,106.27 | $2,469.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.79 / $2,374.73 / $3,163.15
| Professional | | $1,485.79 | $2,374.73 | $3,163.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.31 / $1,177.41 / $1,638.67
| Facility | | $944.31 | $1,177.41 | $1,638.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.55 / $1,732.34 / $2,455.41
| Professional | | $980.55 | $1,732.34 | $2,455.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.55 / $1,732.34 / $2,157.21
| Professional | | $980.55 | $1,732.34 | $2,157.21 |