- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.21 / $1,350.46 / $8,500.00
| Facility | | $330.21 | $1,350.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.21 / $1,350.46 / $1,436.30
| Professional | | $330.21 | $1,350.46 | $1,436.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.44 / $858.61 / $2,829.67
| Professional | | $663.44 | $858.61 | $2,829.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.92 / $1,558.72 / $3,802.82
| Professional | | $448.92 | $1,558.72 | $3,802.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.21 / $1,350.46 / $2,295.78
| Facility | | $330.21 | $1,350.46 | $2,295.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.23 / $2,914.70 / $3,533.20
| Professional | | $1,722.23 | $2,914.70 | $3,533.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.45 / $2,914.70 / $3,533.20
| Professional | | $1,939.45 | $2,914.70 | $3,533.20 |