- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.52 / $609.52 / $8,500.00
| Facility | | $609.52 | $609.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.52 / $609.52 / $610.13
| Professional | | $609.52 | $609.52 | $610.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.69 / $1,248.13 / $1,474.68
| Professional | | $1,149.69 | $1,248.13 | $1,474.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.06 / $1,048.21 / $1,692.02
| Professional | | $809.06 | $1,048.21 | $1,692.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.52 / $729.07 / $1,828.56
| Facility | | $609.52 | $729.07 | $1,828.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.08 / $1,143.16 / $1,560.27
| Professional | | $660.08 | $1,143.16 | $1,560.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.55 / $1,217.58 / $1,560.27
| Professional | | $730.55 | $1,217.58 | $1,560.27 |