- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.81 / $928.81 / $8,500.00
| Facility | | $928.81 | $928.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.34 / $928.81 / $928.81
| Professional | | $875.34 | $928.81 | $928.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.92 / $1,945.38 / $2,332.09
| Professional | | $1,787.92 | $1,945.38 | $2,332.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.41 / $2,173.69 / $2,807.02
| Professional | | $1,120.41 | $2,173.69 | $2,807.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.81 / $1,301.03 / $2,786.43
| Facility | | $928.81 | $1,301.03 | $2,786.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.31 / $1,742.10 / $2,407.31
| Professional | | $964.31 | $1,742.10 | $2,407.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.54 / $1,718.66 / $2,407.31
| Professional | | $1,020.54 | $1,718.66 | $2,407.31 |