- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.08 / $541.08 / $8,500.00
| Facility | | $541.08 | $541.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.08 / $583.17 / $808.92
| Professional | | $541.08 | $583.17 | $808.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.72 / $1,191.30 / $1,407.53
| Professional | | $1,093.72 | $1,191.30 | $1,407.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.26 / $1,004.43 / $1,621.34
| Professional | | $775.26 | $1,004.43 | $1,621.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.08 / $686.54 / $1,623.24
| Facility | | $541.08 | $686.54 | $1,623.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.83 / $1,070.61 / $1,460.17
| Professional | | $608.83 | $1,070.61 | $1,460.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.26 / $1,140.32 / $1,460.17
| Professional | | $671.26 | $1,140.32 | $1,460.17 |