- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.81 / $878.81 / $8,500.00
| Facility | | $878.81 | $878.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.81 / $878.81 / $906.22
| Professional | | $878.81 | $878.81 | $906.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.30 / $1,882.37 / $2,224.03
| Professional | | $1,731.30 | $1,882.37 | $2,224.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.98 / $1,565.13 / $2,526.42
| Professional | | $1,088.98 | $1,565.13 | $2,526.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.81 / $1,202.55 / $2,636.43
| Facility | | $878.81 | $1,202.55 | $2,636.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.95 / $1,787.41 / $2,244.08
| Professional | | $956.95 | $1,787.41 | $2,244.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.08 / $1,903.78 / $2,244.08
| Professional | | $1,047.08 | $1,903.78 | $2,244.08 |