- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.47 / $876.47 / $8,500.00
| Facility | | $876.47 | $876.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.72 / $876.47 / $924.83
| Professional | | $744.72 | $876.47 | $924.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.05 / $1,984.04 / $2,326.39
| Professional | | $1,800.05 | $1,984.04 | $2,326.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.55 / $2,230.42 / $2,970.94
| Professional | | $1,149.55 | $2,230.42 | $2,970.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.47 / $1,260.04 / $1,541.11
| Facility | | $876.47 | $1,260.04 | $1,541.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.35 / $1,607.88 / $2,276.80
| Professional | | $912.35 | $1,607.88 | $2,276.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.35 / $1,525.46 / $2,056.02
| Professional | | $912.35 | $1,525.46 | $2,056.02 |