- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.60 / $985.60 / $8,500.00
| Facility | | $985.60 | $985.60 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.79 / $985.60 / $985.60
| Professional | | $927.79 | $985.60 | $985.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.71 / $2,062.34 / $2,472.30
| Professional | | $1,894.71 | $2,062.34 | $2,472.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.61 / $2,302.77 / $2,973.69
| Professional | | $1,187.61 | $2,302.77 | $2,973.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.60 / $1,378.76 / $2,956.80
| Facility | | $985.60 | $1,378.76 | $2,956.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.14 / $1,925.58 / $2,554.44
| Professional | | $1,023.14 | $1,925.58 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.02 / $2,050.94 / $2,554.44
| Professional | | $1,128.02 | $2,050.94 | $2,554.44 |