- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.58 / $1,504.08 / $8,500.00
| Facility | | $323.58 | $1,504.08 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.58 / $1,504.08 / $1,666.27
| Professional | | $323.58 | $1,504.08 | $1,666.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.84 / $852.66 / $3,202.53
| Professional | | $658.84 | $852.66 | $3,202.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.34 / $2,043.19 / $3,697.38
| Professional | | $402.34 | $2,043.19 | $3,697.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.58 / $1,504.08 / $2,556.94
| Facility | | $323.58 | $1,504.08 | $2,556.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.38 / $2,486.73 / $3,946.23
| Professional | | $1,292.38 | $2,486.73 | $3,946.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.04 / $2,703.34 / $3,946.23
| Professional | | $1,492.04 | $2,703.34 | $3,946.23 |