- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.64 / $774.64 / $8,500.00
| Facility | | $774.64 | $774.64 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.64 / $780.78 / $1,167.83
| Professional | | $774.64 | $780.78 | $1,167.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.85 / $1,671.30 / $2,003.52
| Professional | | $1,531.85 | $1,671.30 | $2,003.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.49 / $1,774.25 / $2,291.19
| Professional | | $1,047.49 | $1,774.25 | $2,291.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.64 / $1,079.08 / $2,323.92
| Facility | | $774.64 | $1,079.08 | $2,323.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.14 / $1,462.26 / $1,990.16
| Professional | | $831.14 | $1,462.26 | $1,990.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.14 / $1,557.46 / $1,990.16
| Professional | | $831.14 | $1,557.46 | $1,990.16 |