- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.13 / $748.13 / $8,500.00
| Facility | | $748.13 | $748.13 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.86 / $748.13 / $1,218.53
| Professional | | $631.86 | $748.13 | $1,218.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.77 / $1,679.52 / $1,969.34
| Professional | | $1,523.77 | $1,679.52 | $1,969.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.12 / $1,858.27 / $2,475.21
| Professional | | $930.12 | $1,858.27 | $2,475.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.13 / $941.58 / $1,301.08
| Facility | | $748.13 | $941.58 | $1,301.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.67 / $1,388.45 / $1,936.60
| Professional | | $785.67 | $1,388.45 | $1,936.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.67 / $1,388.45 / $1,728.47
| Professional | | $785.67 | $1,388.45 | $1,728.47 |