- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.69 / $950.69 / $8,500.00
| Facility | | $950.69 | $950.69 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.23 / $950.69 / $950.69
| Professional | | $929.23 | $950.69 | $950.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.01 / $2,174.38 / $2,606.60
| Professional | | $1,997.01 | $2,174.38 | $2,606.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.54 / $2,252.12 / $2,908.29
| Professional | | $1,230.54 | $2,252.12 | $2,908.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.69 / $1,379.51 / $2,852.07
| Facility | | $950.69 | $1,379.51 | $2,852.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.46 / $1,783.56 / $2,432.26
| Professional | | $1,040.46 | $1,783.56 | $2,432.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.46 / $1,899.68 / $2,432.26
| Professional | | $1,040.46 | $1,899.68 | $2,432.26 |