- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.02 / $593.02 / $8,500.00
| Facility | | $593.02 | $593.02 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.63 / $593.02 / $615.59
| Professional | | $541.63 | $593.02 | $615.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.79 / $1,335.23 / $1,565.63
| Professional | | $1,213.79 | $1,335.23 | $1,565.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.53 / $1,483.58 / $1,976.13
| Professional | | $757.53 | $1,483.58 | $1,976.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.02 / $746.40 / $1,030.09
| Facility | | $593.02 | $746.40 | $1,030.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.82 / $1,087.90 / $1,536.02
| Professional | | $621.82 | $1,087.90 | $1,536.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.82 / $1,087.90 / $1,368.00
| Professional | | $621.82 | $1,087.90 | $1,368.00 |