- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.65 / $794.65 / $8,500.00
| Facility | | $794.65 | $794.65 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.25 / $780.25 / $822.67
| Professional | | $715.25 | $780.25 | $822.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.07 / $1,720.79 / $2,024.46
| Professional | | $1,551.07 | $1,720.79 | $2,024.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.86 / $1,864.18 / $2,483.09
| Professional | | $1,015.86 | $1,864.18 | $2,483.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.65 / $1,234.59 / $1,433.90
| Facility | | $794.65 | $1,234.59 | $1,433.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.58 / $1,461.33 / $2,046.23
| Professional | | $845.58 | $1,461.33 | $2,046.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.58 / $1,461.33 / $1,715.09
| Professional | | $845.58 | $1,461.33 | $1,715.09 |