- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.42 / $879.42 / $8,500.00
| Facility | | $879.42 | $879.42 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.60 / $879.42 / $879.42
| Professional | | $859.60 | $879.42 | $879.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.75 / $2,010.91 / $2,410.64
| Professional | | $1,847.75 | $2,010.91 | $2,410.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.53 / $2,083.03 / $2,689.93
| Professional | | $1,138.53 | $2,083.03 | $2,689.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.42 / $1,276.08 / $2,638.26
| Facility | | $879.42 | $1,276.08 | $2,638.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.06 / $1,432.32 / $2,249.63
| Professional | | $822.06 | $1,432.32 | $2,249.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.39 / $1,613.30 / $2,249.63
| Professional | | $859.39 | $1,613.30 | $2,249.63 |