- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.07 / $903.07 / $8,500.00
| Facility | | $903.07 | $903.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.89 / $903.07 / $903.07
| Professional | | $817.89 | $903.07 | $903.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.74 / $1,927.06 / $2,310.12
| Professional | | $1,755.74 | $1,927.06 | $2,310.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.57 / $2,097.73 / $2,708.92
| Professional | | $1,114.57 | $2,097.73 | $2,708.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.07 / $1,262.48 / $2,709.21
| Facility | | $903.07 | $1,262.48 | $2,709.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.61 / $1,673.94 / $2,333.67
| Professional | | $980.61 | $1,673.94 | $2,333.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.80 / $1,782.92 / $2,333.67
| Professional | | $948.80 | $1,782.92 | $2,333.67 |