- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.27 / $727.27 / $8,500.00
| Facility | | $727.27 | $727.27 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.82 / $727.27 / $1,136.16
| Professional | | $717.82 | $727.27 | $1,136.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.73 / $1,603.13 / $1,894.11
| Professional | | $1,470.73 | $1,603.13 | $1,894.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.58 / $1,350.78 / $2,180.42
| Professional | | $1,042.58 | $1,350.78 | $2,180.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.27 / $922.79 / $2,181.81
| Facility | | $727.27 | $922.79 | $2,181.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.79 / $1,438.83 / $1,962.82
| Professional | | $817.79 | $1,438.83 | $1,962.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.64 / $1,532.50 / $1,962.82
| Professional | | $901.64 | $1,532.50 | $1,962.82 |