- 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
- $870.34 / $945.04 / $980.35
| Professional | | $870.34 | $945.04 | $980.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.26 / $2,107.73 / $2,471.42
| Professional | | $1,912.26 | $2,107.73 | $2,471.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.60 / $2,321.57 / $3,092.34
| Professional | | $1,387.60 | $2,321.57 | $3,092.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.62 / $1,596.60 / $1,727.65
| Facility | | $944.62 | $1,596.60 | $1,727.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.55 / $1,762.61 / $2,442.48
| Professional | | $1,032.55 | $1,762.61 | $2,442.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.99 / $1,761.13 / $2,442.48
| Professional | | $994.99 | $1,761.13 | $2,442.48 |