- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.96 / $827.96 / $8,500.00
| Facility | | $827.96 | $827.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.13 / $827.96 / $827.96
| Professional | | $753.13 | $827.96 | $827.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.56 / $1,771.35 / $2,123.46
| Professional | | $1,613.56 | $1,771.35 | $2,123.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.01 / $1,931.91 / $2,494.78
| Professional | | $1,025.01 | $1,931.91 | $2,494.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.96 / $1,136.77 / $2,483.88
| Facility | | $827.96 | $1,136.77 | $2,483.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.68 / $1,537.50 / $2,140.41
| Professional | | $900.68 | $1,537.50 | $2,140.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.68 / $1,637.60 / $2,140.41
| Professional | | $900.68 | $1,637.60 | $2,140.41 |