- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.94 / $848.94 / $8,500.00
| Facility | | $848.94 | $848.94 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.31 / $848.94 / $941.73
| Professional | | $805.31 | $848.94 | $941.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.76 / $1,768.49 / $2,073.66
| Professional | | $1,588.76 | $1,768.49 | $2,073.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.16 / $2,010.17 / $2,677.55
| Professional | | $1,006.16 | $2,010.17 | $2,677.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.94 / $1,141.25 / $1,443.20
| Facility | | $848.94 | $1,141.25 | $1,443.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.76 / $1,652.54 / $2,210.59
| Professional | | $869.76 | $1,652.54 | $2,210.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.76 / $1,594.14 / $1,913.47
| Professional | | $869.76 | $1,594.14 | $1,913.47 |