- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.61 / $790.61 / $8,500.00
| Facility | | $790.61 | $790.61 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.41 / $790.61 / $820.26
| Professional | | $715.41 | $790.61 | $820.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.76 / $1,768.49 / $2,073.66
| Professional | | $1,588.76 | $1,768.49 | $2,073.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.43 / $1,952.78 / $2,601.11
| Professional | | $977.43 | $1,952.78 | $2,601.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.61 / $988.59 / $1,359.74
| Facility | | $790.61 | $988.59 | $1,359.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.50 / $1,474.65 / $2,045.40
| Professional | | $831.50 | $1,474.65 | $2,045.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.50 / $1,453.84 / $1,829.30
| Professional | | $831.50 | $1,453.84 | $1,829.30 |