- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $715.15 / $715.15 / $8,500.00
| Facility | | $715.15 | $715.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.13 / $715.15 / $715.15
| Professional | | $694.13 | $715.15 | $715.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.84 / $1,828.17 / $2,360.81
| Professional | | $1,128.84 | $1,828.17 | $2,360.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.81 / $715.15 / $2,145.44
| Facility | | $392.81 | $715.15 | $2,145.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.75 / $1,409.59 / $1,939.72
| Professional | | $825.75 | $1,409.59 | $1,939.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.41 / $1,501.36 / $1,939.72
| Professional | | $871.41 | $1,501.36 | $1,939.72 |