- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.47 / $759.47 / $8,500.00
| Facility | | $759.47 | $759.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.60 / $759.47 / $837.98
| Professional | | $672.60 | $759.47 | $837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.86 / $1,692.44 / $2,028.86
| Professional | | $1,540.86 | $1,692.44 | $2,028.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.22 / $1,759.55 / $2,272.19
| Professional | | $969.22 | $1,759.55 | $2,272.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.47 / $1,021.97 / $2,278.41
| Facility | | $759.47 | $1,021.97 | $2,278.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.48 / $1,403.43 / $1,946.92
| Professional | | $822.48 | $1,403.43 | $1,946.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,319.46 / $11,319.46 / $11,319.46
| Facility | | $11,319.46 | $11,319.46 | $11,319.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.48 / $1,494.80 / $1,946.92
| Professional | | $822.48 | $1,494.80 | $1,946.92 |