- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.72 / $638.67 / $8,500.00
| Facility | | $525.72 | $638.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.96 / $529.64 / $711.16
| Professional | | $448.96 | $529.64 | $711.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.38 / $1,265.74 / $1,489.11
| Professional | | $1,051.38 | $1,265.74 | $1,489.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.28 / $1,332.46 / $1,985.27
| Professional | | $949.28 | $1,332.46 | $1,985.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.72 / $683.44 / $1,577.16
| Facility | | $525.72 | $683.44 | $1,577.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.66 / $1,171.66 / $5,064.29
| Professional | | $654.66 | $1,171.66 | $5,064.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.66 / $1,086.49 / $1,665.55
| Professional | | $654.66 | $1,086.49 | $1,665.55 |