- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.76 / $757.43 / $8,500.00
| Facility | | $617.76 | $757.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.16 / $617.76 / $757.43
| Professional | | $579.16 | $617.76 | $757.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.83 / $1,504.42 / $1,878.61
| Professional | | $1,234.83 | $1,504.42 | $1,878.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.23 / $1,511.42 / $2,332.33
| Professional | | $925.23 | $1,511.42 | $2,332.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.76 / $874.64 / $1,853.28
| Facility | | $617.76 | $874.64 | $1,853.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.84 / $1,365.16 / $1,969.60
| Professional | | $750.84 | $1,365.16 | $1,969.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.31 / $1,365.16 / $1,969.60
| Professional | | $785.31 | $1,365.16 | $1,969.60 |