- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.48 / $886.48 / $8,500.00
| Facility | | $886.48 | $886.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.48 / $886.48 / $900.30
| Professional | | $886.48 | $886.48 | $900.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.75 / $1,922.83 / $2,305.05
| Professional | | $1,764.75 | $1,922.83 | $2,305.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.31 / $2,043.82 / $2,639.30
| Professional | | $1,160.31 | $2,043.82 | $2,639.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.48 / $1,243.25 / $2,659.44
| Facility | | $886.48 | $1,243.25 | $2,659.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.60 / $1,676.47 / $2,277.84
| Professional | | $950.60 | $1,676.47 | $2,277.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.60 / $1,785.62 / $2,277.84
| Professional | | $950.60 | $1,785.62 | $2,277.84 |