- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.82 / $844.82 / $8,500.00
| Facility | | $844.82 | $844.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.84 / $844.82 / $844.82
| Professional | | $795.84 | $844.82 | $844.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.57 / $1,766.42 / $2,117.55
| Professional | | $1,622.57 | $1,766.42 | $2,117.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.19 / $1,973.57 / $2,548.58
| Professional | | $1,018.19 | $1,973.57 | $2,548.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.82 / $1,181.25 / $2,534.46
| Facility | | $844.82 | $1,181.25 | $2,534.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.98 / $1,586.29 / $2,189.73
| Professional | | $876.98 | $1,586.29 | $2,189.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.98 / $1,689.56 / $2,189.73
| Professional | | $876.98 | $1,689.56 | $2,189.73 |