- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.14 / $948.14 / $8,500.00
| Facility | | $948.14 | $948.14 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.14 / $948.14 / $982.16
| Professional | | $948.14 | $948.14 | $982.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.77 / $2,036.01 / $2,405.57
| Professional | | $1,874.77 | $2,036.01 | $2,405.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.88 / $1,700.41 / $2,744.78
| Professional | | $1,284.88 | $1,700.41 | $2,744.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.14 / $1,304.66 / $2,844.42
| Facility | | $948.14 | $1,304.66 | $2,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.52 / $2,029.15 / $2,422.64
| Professional | | $1,032.52 | $2,029.15 | $2,422.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.69 / $1,945.13 / $2,222.39
| Professional | | $1,188.69 | $1,945.13 | $2,222.39 |