- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.17 / $961.17 / $8,500.00
| Facility | | $961.17 | $961.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.17 / $961.17 / $967.27
| Professional | | $961.17 | $961.17 | $967.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.79 / $2,072.21 / $2,484.12
| Professional | | $1,901.79 | $2,072.21 | $2,484.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.07 / $2,199.03 / $2,839.72
| Professional | | $1,194.07 | $2,199.03 | $2,839.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.17 / $1,338.39 / $2,883.51
| Facility | | $961.17 | $1,338.39 | $2,883.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.80 / $1,803.88 / $2,468.91
| Professional | | $1,031.80 | $1,803.88 | $2,468.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.73 / $1,921.32 / $2,468.91
| Professional | | $1,056.73 | $1,921.32 | $2,468.91 |