- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.78 / $595.26 / $8,500.00
| Facility | | $431.78 | $595.26 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.61 / $536.62 / $595.26
| Professional | | $404.61 | $536.62 | $595.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.85 / $1,006.68 / $1,283.50
| Professional | | $777.85 | $1,006.68 | $1,283.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.08 / $982.95 / $1,644.55
| Professional | | $582.08 | $982.95 | $1,644.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.78 / $595.26 / $1,295.33
| Facility | | $431.78 | $595.26 | $1,295.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.83 / $1,092.00 / $1,554.14
| Professional | | $608.83 | $1,092.00 | $1,554.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.61 / $1,132.02 / $1,554.14
| Professional | | $622.61 | $1,132.02 | $1,554.14 |