- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.33 / $776.33 / $8,500.00
| Facility | | $776.33 | $776.33 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.33 / $776.33 / $788.27
| Professional | | $776.33 | $776.33 | $788.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.72 / $1,683.27 / $2,017.87
| Professional | | $1,544.72 | $1,683.27 | $2,017.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.67 / $1,794.67 / $2,317.56
| Professional | | $1,030.67 | $1,794.67 | $2,317.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.33 / $1,090.44 / $2,328.98
| Facility | | $776.33 | $1,090.44 | $2,328.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.78 / $1,464.19 / $1,996.32
| Professional | | $830.78 | $1,464.19 | $1,996.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.78 / $1,487.10 / $1,996.32
| Professional | | $830.78 | $1,487.10 | $1,996.32 |