- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.67 / $531.67 / $8,500.00
| Facility | | $531.67 | $531.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.14 / $531.67 / $531.67
| Professional | | $494.14 | $531.67 | $531.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.66 / $1,101.28 / $1,320.20
| Professional | | $1,012.66 | $1,101.28 | $1,320.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.57 / $1,222.05 / $1,578.09
| Professional | | $636.57 | $1,222.05 | $1,578.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.67 / $734.18 / $1,595.04
| Facility | | $531.67 | $734.18 | $1,595.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.61 / $1,003.68 / $1,376.05
| Professional | | $553.61 | $1,003.68 | $1,376.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.96 / $1,069.02 / $1,376.05
| Professional | | $587.96 | $1,069.02 | $1,376.05 |