- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.26 / $780.26 / $8,500.00
| Facility | | $780.26 | $780.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.37 / $780.26 / $780.26
| Professional | | $720.37 | $780.26 | $780.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.07 / $1,688.91 / $2,023.62
| Professional | | $1,535.07 | $1,688.91 | $2,023.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.87 / $1,844.50 / $2,381.91
| Professional | | $975.87 | $1,844.50 | $2,381.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.26 / $1,107.53 / $2,340.78
| Facility | | $780.26 | $1,107.53 | $2,340.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.36 / $1,431.39 / $2,018.68
| Professional | | $816.36 | $1,431.39 | $2,018.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.40 / $1,558.37 / $2,018.68
| Professional | | $805.40 | $1,558.37 | $2,018.68 |