- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.81 / $906.81 / $8,500.00
| Facility | | $906.81 | $906.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.96 / $906.81 / $906.81
| Professional | | $852.96 | $906.81 | $906.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.59 / $1,895.35 / $2,272.12
| Professional | | $1,741.59 | $1,895.35 | $2,272.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.61 / $2,115.71 / $2,732.13
| Professional | | $1,092.61 | $2,115.71 | $2,732.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.81 / $1,267.04 / $2,720.43
| Facility | | $906.81 | $1,267.04 | $2,720.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.94 / $1,703.14 / $2,349.81
| Professional | | $941.94 | $1,703.14 | $2,349.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.94 / $1,814.02 / $2,349.81
| Professional | | $941.94 | $1,814.02 | $2,349.81 |