- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.31 / $772.31 / $8,500.00
| Facility | | $772.31 | $772.31 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.85 / $772.31 / $846.10
| Professional | | $708.85 | $772.31 | $846.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.57 / $1,510.65 / $1,798.86
| Professional | | $1,364.57 | $1,510.65 | $1,798.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.50 / $1,693.38 / $2,186.76
| Professional | | $981.50 | $1,693.38 | $2,186.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.31 / $1,002.62 / $2,316.92
| Facility | | $772.31 | $1,002.62 | $2,316.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.22 / $1,426.62 / $2,009.27
| Professional | | $797.22 | $1,426.62 | $2,009.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.22 / $1,519.50 / $2,009.27
| Professional | | $797.22 | $1,519.50 | $2,009.27 |