- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $638.57 / $638.57 / $8,500.00
| Facility | | $638.57 | $638.57 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.57 / $642.98 / $1,002.85
| Professional | | $638.57 | $642.98 | $1,002.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.30 / $1,388.45 / $1,640.46
| Professional | | $1,280.30 | $1,388.45 | $1,640.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.89 / $1,197.86 / $1,933.59
| Professional | | $798.89 | $1,197.86 | $1,933.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $638.57 / $844.14 / $1,915.71
| Facility | | $638.57 | $844.14 | $1,915.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.91 / $1,173.08 / $1,643.13
| Professional | | $584.91 | $1,173.08 | $1,643.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.20 / $1,249.46 / $1,643.13
| Professional | | $687.20 | $1,249.46 | $1,643.13 |