- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.33 / $537.33 / $8,500.00
| Facility | | $537.33 | $537.33 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.66 / $537.33 / $560.52
| Professional | | $480.66 | $537.33 | $560.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.93 / $1,212.56 / $1,426.54
| Professional | | $1,085.93 | $1,212.56 | $1,426.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.84 / $1,350.24 / $1,798.52
| Professional | | $675.84 | $1,350.24 | $1,798.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.33 / $680.09 / $937.98
| Facility | | $537.33 | $680.09 | $937.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.72 / $985.73 / $1,391.53
| Professional | | $563.72 | $985.73 | $1,391.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.72 / $985.73 / $1,391.53
| Professional | | $563.72 | $985.73 | $1,391.53 |