- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.48 / $760.48 / $8,500.00
| Facility | | $760.48 | $760.48 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.48 / $760.48 / $809.88
| Professional | | $760.48 | $760.48 | $809.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.45 / $1,627.69 / $1,923.12
| Professional | | $1,509.45 | $1,627.69 | $1,923.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.48 / $1,407.64 / $2,272.19
| Professional | | $1,086.48 | $1,407.64 | $2,272.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.48 / $1,066.43 / $2,281.44
| Facility | | $760.48 | $1,066.43 | $2,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.06 / $1,439.15 / $1,955.62
| Professional | | $785.06 | $1,439.15 | $1,955.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.06 / $1,532.84 / $1,955.62
| Professional | | $843.06 | $1,532.84 | $1,955.62 |