- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $576.77 / $576.77 / $8,500.00
| Facility | | $576.77 | $576.77 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.66 / $576.77 / $596.84
| Professional | | $515.66 | $576.77 | $596.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.34 / $1,293.28 / $1,516.43
| Professional | | $1,173.34 | $1,293.28 | $1,516.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.24 / $1,432.94 / $1,908.68
| Professional | | $717.24 | $1,432.94 | $1,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $576.77 / $722.95 / $996.32
| Facility | | $576.77 | $722.95 | $996.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.58 / $1,068.84 / $1,493.22
| Professional | | $605.58 | $1,068.84 | $1,493.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.58 / $1,058.08 / $1,332.28
| Professional | | $605.58 | $1,058.08 | $1,332.28 |