- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.70 / $1,109.65 / $8,500.00
| Facility | | $311.70 | $1,109.65 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.70 / $1,094.76 / $1,961.41
| Professional | | $311.70 | $1,094.76 | $1,961.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.48 / $1,628.47 / $2,560.48
| Professional | | $636.48 | $1,628.47 | $2,560.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.34 / $937.78 / $2,940.20
| Professional | | $387.34 | $937.78 | $2,940.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.70 / $1,109.65 / $1,886.41
| Facility | | $311.70 | $1,109.65 | $1,886.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.13 / $1,838.66 / $2,906.73
| Professional | | $923.13 | $1,838.66 | $2,906.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.20 / $2,035.65 / $2,906.73
| Professional | | $1,103.20 | $2,035.65 | $2,906.73 |