- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.22 / $928.22 / $8,500.00
| Facility | | $928.22 | $928.22 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.37 / $928.22 / $928.22
| Professional | | $875.37 | $928.22 | $928.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.48 / $1,938.33 / $2,323.64
| Professional | | $1,781.48 | $1,938.33 | $2,323.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.63 / $2,167.17 / $2,798.58
| Professional | | $1,121.63 | $2,167.17 | $2,798.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.22 / $1,297.10 / $2,784.66
| Facility | | $928.22 | $1,297.10 | $2,784.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.40 / $1,739.28 / $2,404.94
| Professional | | $965.40 | $1,739.28 | $2,404.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.40 / $1,852.52 / $2,404.94
| Professional | | $965.40 | $1,852.52 | $2,404.94 |