- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.07 / $847.07 / $8,500.00
| Facility | | $847.07 | $847.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.47 / $846.88 / $915.20
| Professional | | $765.47 | $846.88 | $915.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.14 / $1,977.53 / $2,318.76
| Professional | | $1,794.14 | $1,977.53 | $2,318.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.65 / $2,119.03 / $2,822.56
| Professional | | $1,060.65 | $2,119.03 | $2,822.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.07 / $1,019.72 / $1,489.19
| Facility | | $847.07 | $1,019.72 | $1,489.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.29 / $1,564.02 / $2,181.26
| Professional | | $907.29 | $1,564.02 | $2,181.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.29 / $1,645.46 / $2,181.26
| Professional | | $907.29 | $1,645.46 | $2,181.26 |