- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.38 / $778.38 / $8,500.00
| Facility | | $778.38 | $778.38 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.47 / $778.38 / $836.22
| Professional | | $685.47 | $778.38 | $836.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.58 / $1,800.31 / $2,110.96
| Professional | | $1,636.58 | $1,800.31 | $2,110.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.38 / $2,018.61 / $2,688.79
| Professional | | $1,010.38 | $2,018.61 | $2,688.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.62 / $1,006.38 / $1,396.04
| Facility | | $751.62 | $1,006.38 | $1,396.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.02 / $1,427.94 / $2,020.24
| Professional | | $812.02 | $1,427.94 | $2,020.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.02 / $1,427.94 / $1,679.98
| Professional | | $812.02 | $1,427.94 | $1,679.98 |