- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.60 / $888.82 / $8,500.00
| Facility | | $508.60 | $888.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.85 / $508.60 / $854.12
| Professional | | $428.85 | $508.60 | $854.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.17 / $1,146.44 / $1,344.27
| Professional | | $1,042.17 | $1,146.44 | $1,344.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.47 / $1,283.57 / $1,709.72
| Professional | | $642.47 | $1,283.57 | $1,709.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.60 / $879.30 / $3,642.45
| Facility | | $508.60 | $879.30 | $3,642.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.16 / $965.61 / $1,319.85
| Professional | | $530.16 | $965.61 | $1,319.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.16 / $910.14 / $1,319.85
| Professional | | $530.16 | $910.14 | $1,319.85 |