- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.32 / $510.32 / $8,500.00
| Facility | | $510.32 | $510.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.97 / $526.04 / $541.34
| Professional | | $498.97 | $526.04 | $541.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.00 / $1,155.13 / $1,354.45
| Professional | | $1,048.00 | $1,155.13 | $1,354.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.76 / $1,302.14 / $1,734.45
| Professional | | $651.76 | $1,302.14 | $1,734.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.32 / $892.40 / $1,045.78
| Facility | | $510.32 | $892.40 | $1,045.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.35 / $981.00 / $1,325.90
| Professional | | $528.35 | $981.00 | $1,325.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.35 / $936.18 / $1,162.36
| Professional | | $528.35 | $936.18 | $1,162.36 |