- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.72 / $876.72 / $8,500.00
| Facility | | $876.72 | $876.72 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.83 / $876.72 / $876.72
| Professional | | $826.83 | $876.72 | $876.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.55 / $1,835.46 / $2,200.32
| Professional | | $1,687.55 | $1,835.46 | $2,200.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.83 / $2,051.98 / $2,649.85
| Professional | | $1,057.83 | $2,051.98 | $2,649.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.72 / $1,228.14 / $2,630.16
| Facility | | $876.72 | $1,228.14 | $2,630.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.18 / $1,655.11 / $2,272.44
| Professional | | $910.18 | $1,655.11 | $2,272.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.18 / $1,655.11 / $2,272.44
| Professional | | $910.18 | $1,655.11 | $2,272.44 |