- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.03 / $921.03 / $8,500.00
| Facility | | $921.03 | $921.03 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.25 / $919.30 / $1,148.85
| Professional | | $804.25 | $919.30 | $1,148.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.03 / $2,054.92 / $2,409.51
| Professional | | $1,868.03 | $2,054.92 | $2,409.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.45 / $2,262.50 / $3,013.65
| Professional | | $1,132.45 | $2,262.50 | $3,013.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.03 / $1,275.25 / $1,577.36
| Facility | | $921.03 | $1,275.25 | $1,577.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.73 / $1,689.63 / $2,381.71
| Professional | | $969.73 | $1,689.63 | $2,381.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.73 / $1,689.63 / $2,133.41
| Professional | | $969.73 | $1,689.63 | $2,133.41 |