- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.05 / $997.05 / $8,500.00
| Facility | | $997.05 | $997.05 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.87 / $996.80 / $1,034.54
| Professional | | $922.87 | $996.80 | $1,034.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.57 / $2,224.90 / $2,608.82
| Professional | | $2,018.57 | $2,224.90 | $2,608.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.80 / $2,449.00 / $3,262.07
| Professional | | $1,225.80 | $2,449.00 | $3,262.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.05 / $1,374.14 / $1,784.45
| Facility | | $997.05 | $1,374.14 | $1,784.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.21 / $1,857.43 / $2,577.92
| Professional | | $1,050.21 | $1,857.43 | $2,577.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.21 / $1,829.09 / $2,310.46
| Professional | | $1,050.21 | $1,829.09 | $2,310.46 |