- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.75 / $818.75 / $8,500.00
| Facility | | $818.75 | $818.75 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.75 / $818.75 / $876.97
| Professional | | $818.75 | $818.75 | $876.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.49 / $1,767.83 / $2,119.23
| Professional | | $1,615.49 | $1,767.83 | $2,119.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.52 / $1,981.74 / $2,559.13
| Professional | | $1,144.52 | $1,981.74 | $2,559.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.75 / $1,150.27 / $2,456.25
| Facility | | $818.75 | $1,150.27 | $2,456.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.74 / $1,549.16 / $2,127.30
| Professional | | $847.74 | $1,549.16 | $2,127.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,477.18 / $11,477.18 / $11,477.18
| Facility | | $11,477.18 | $11,477.18 | $11,477.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.01 / $1,650.02 / $2,127.30
| Professional | | $990.01 | $1,650.02 | $2,127.30 |