- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.01 / $981.01 / $8,500.00
| Facility | | $981.01 | $981.01 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.01 / $981.01 / $1,009.74
| Professional | | $981.01 | $981.01 | $1,009.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.38 / $2,100.56 / $2,481.83
| Professional | | $1,931.38 | $2,100.56 | $2,481.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.88 / $1,742.88 / $2,813.35
| Professional | | $1,309.88 | $1,742.88 | $2,813.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.01 / $1,340.33 / $2,943.03
| Facility | | $981.01 | $1,340.33 | $2,943.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.78 / $2,010.73 / $2,504.31
| Professional | | $1,070.78 | $2,010.73 | $2,504.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.90 / $2,141.64 / $2,504.31
| Professional | | $1,177.90 | $2,141.64 | $2,504.31 |