- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.54 / $554.54 / $8,500.00
| Facility | | $554.54 | $554.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.36 / $554.54 / $554.54
| Professional | | $496.36 | $554.54 | $554.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.21 / $3,324.05 / $3,910.65
| Professional | | $3,098.21 | $3,324.05 | $3,910.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.90 / $2,681.28 / $3,780.67
| Professional | | $674.90 | $2,681.28 | $3,780.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.54 / $846.38 / $1,663.65
| Facility | | $554.54 | $846.38 | $1,663.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.24 / $1,674.63 / $2,915.39
| Professional | | $1,100.24 | $1,674.63 | $2,915.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.24 / $1,491.92 / $2,915.39
| Professional | | $1,100.24 | $1,491.92 | $2,915.39 |