- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.54 / $2,390.63 / $2,500.00
| Facility | | $523.54 | $2,390.63 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.12 / $523.54 / $872.08
| Professional | | $453.12 | $523.54 | $872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.48 / $1,175.38 / $1,378.20
| Professional | | $1,068.48 | $1,175.38 | $1,378.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.10 / $1,314.80 / $1,751.31
| Professional | | $658.10 | $1,314.80 | $1,751.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.54 / $831.05 / $1,570.65
| Facility | | $523.54 | $831.05 | $1,570.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.04 / $980.04 / $1,358.27
| Professional | | $546.04 | $980.04 | $1,358.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.04 / $960.45 / $1,358.27
| Professional | | $546.04 | $960.45 | $1,358.27 |