- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.63 / $785.63 / $8,500.00
| Facility | | $785.63 | $785.63 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.82 / $785.63 / $1,212.26
| Professional | | $715.82 | $785.63 | $1,212.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.14 / $1,681.87 / $2,016.19
| Professional | | $1,533.14 | $1,681.87 | $2,016.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.40 / $1,835.52 / $2,370.30
| Professional | | $973.40 | $1,835.52 | $2,370.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.63 / $1,065.84 / $2,356.89
| Facility | | $785.63 | $1,065.84 | $2,356.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.11 / $1,531.59 / $2,031.27
| Professional | | $867.11 | $1,531.59 | $2,031.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.22 / $1,631.30 / $2,090.11
| Professional | | $897.22 | $1,631.30 | $2,090.11 |