- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.76 / $501.76 / $8,500.00
| Facility | | $501.76 | $501.76 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.93 / $501.76 / $575.62
| Professional | | $403.93 | $501.76 | $575.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.92 / $1,193.46 / $1,399.40
| Professional | | $1,084.92 | $1,193.46 | $1,399.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.38 / $1,228.58 / $1,663.99
| Professional | | $616.38 | $1,228.58 | $1,663.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.76 / $667.15 / $893.48
| Facility | | $501.76 | $667.15 | $893.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.34 / $920.48 / $1,290.26
| Professional | | $541.34 | $920.48 | $1,290.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.34 / $920.48 / $1,290.26
| Professional | | $541.34 | $920.48 | $1,290.26 |