- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.06 / $816.06 / $8,500.00
| Facility | | $816.06 | $816.06 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.79 / $816.06 / $816.06
| Professional | | $741.79 | $816.06 | $816.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.47 / $1,743.87 / $2,090.52
| Professional | | $1,588.47 | $1,743.87 | $2,090.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.55 / $1,900.87 / $2,454.69
| Professional | | $1,009.55 | $1,900.87 | $2,454.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.06 / $1,143.34 / $2,448.17
| Facility | | $816.06 | $1,143.34 | $2,448.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.25 / $1,497.06 / $2,109.46
| Professional | | $876.25 | $1,497.06 | $2,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.25 / $1,540.64 / $2,109.46
| Professional | | $876.25 | $1,540.64 | $2,109.46 |