- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.86 / $1,191.35 / $8,500.00
| Facility | | $874.86 | $1,191.35 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.50 / $1,148.46 / $1,191.35
| Professional | | $812.50 | $1,148.46 | $1,191.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.86 / $2,239.04 / $2,936.56
| Professional | | $1,735.86 | $2,239.04 | $2,936.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.52 / $2,212.42 / $3,701.56
| Professional | | $1,263.52 | $2,212.42 | $3,701.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.86 / $1,226.33 / $2,624.58
| Facility | | $874.86 | $1,226.33 | $2,624.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.18 / $2,182.46 / $3,100.02
| Professional | | $1,233.18 | $2,182.46 | $3,100.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.34 / $2,185.55 / $3,100.02
| Professional | | $1,200.34 | $2,185.55 | $3,100.02 |