- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.46 / $895.46 / $8,500.00
| Facility | | $895.46 | $895.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.86 / $895.46 / $895.46
| Professional | | $842.86 | $895.46 | $895.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.00 / $1,873.51 / $2,245.94
| Professional | | $1,721.00 | $1,873.51 | $2,245.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.47 / $2,090.38 / $2,699.43
| Professional | | $1,079.47 | $2,090.38 | $2,699.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.46 / $1,251.98 / $2,686.38
| Facility | | $895.46 | $1,251.98 | $2,686.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.03 / $1,692.17 / $2,320.48
| Professional | | $930.03 | $1,692.17 | $2,320.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.03 / $1,765.88 / $2,320.48
| Professional | | $930.03 | $1,765.88 | $2,320.48 |