- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.67 / $960.67 / $8,500.00
| Facility | | $960.67 | $960.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.37 / $960.67 / $996.92
| Professional | | $880.37 | $960.67 | $996.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.59 / $2,142.44 / $2,512.13
| Professional | | $1,947.59 | $2,142.44 | $2,512.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.49 / $2,362.08 / $3,146.29
| Professional | | $1,195.49 | $2,362.08 | $3,146.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.67 / $1,222.91 / $1,645.85
| Facility | | $960.67 | $1,222.91 | $1,645.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.59 / $1,793.42 / $2,484.19
| Professional | | $1,011.59 | $1,793.42 | $2,484.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.59 / $1,762.35 / $2,073.41
| Professional | | $1,011.59 | $1,762.35 | $2,073.41 |