- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $8,511.38
| Facility | | $912.01 | $1,000.00 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,041.74
| Professional | | $912.01 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,630.27
| Professional | | $1,862.09 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,819.70 / $2,818.38
| Professional | | $1,071.52 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,137.96
| Facility | | $977.24 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $7,413.10
| Professional | | $912.01 | $1,621.81 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $2,187.76
| Professional | | $912.01 | $1,380.38 | $2,187.76 |