- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.62 / $944.62 / $8,500.00
| Facility | | $944.62 | $944.62 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.34 / $944.62 / $944.62
| Professional | | $863.34 | $944.62 | $944.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.18 / $2,033.46 / $2,437.67
| Professional | | $1,854.18 | $2,033.46 | $2,437.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.50 / $2,214.55 / $2,859.77
| Professional | | $1,177.50 | $2,214.55 | $2,859.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.62 / $1,199.85 / $2,833.86
| Facility | | $944.62 | $1,199.85 | $2,833.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.13 / $1,737.14 / $2,443.23
| Professional | | $1,011.13 | $1,737.14 | $2,443.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.63 / $1,850.24 / $2,443.23
| Professional | | $1,017.63 | $1,850.24 | $2,443.23 |