- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.62 / $654.32 / $8,500.00
| Facility | | $518.62 | $654.32 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.62 / $654.32 / $688.43
| Professional | | $518.62 | $654.32 | $688.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.11 / $1,275.59 / $1,595.50
| Professional | | $1,023.11 | $1,275.59 | $1,595.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.07 / $1,289.48 / $2,027.47
| Professional | | $629.07 | $1,289.48 | $2,027.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.62 / $738.33 / $1,555.86
| Facility | | $518.62 | $738.33 | $1,555.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.47 / $1,292.02 / $1,711.25
| Professional | | $668.47 | $1,292.02 | $1,711.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.88 / $1,238.53 / $1,711.25
| Professional | | $756.88 | $1,238.53 | $1,711.25 |