- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.66 / $810.66 / $8,500.00
| Facility | | $810.66 | $810.66 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.22 / $810.66 / $810.66
| Professional | | $737.22 | $810.66 | $810.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.82 / $1,733.30 / $2,077.85
| Professional | | $1,578.82 | $1,733.30 | $2,077.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.32 / $1,889.43 / $2,439.92
| Professional | | $1,003.32 | $1,889.43 | $2,439.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.66 / $1,136.54 / $2,431.98
| Facility | | $810.66 | $1,136.54 | $2,431.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.21 / $1,490.61 / $2,095.60
| Professional | | $873.21 | $1,490.61 | $2,095.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.21 / $1,770.06 / $2,095.60
| Professional | | $873.21 | $1,770.06 | $2,095.60 |