- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.87 / $432.83 / $8,500.00
| Facility | | $354.87 | $432.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.22 / $412.26 / $432.83
| Professional | | $330.22 | $412.26 | $432.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.40 / $856.75 / $1,064.77
| Professional | | $690.40 | $856.75 | $1,064.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.40 / $843.90 / $1,329.14
| Professional | | $504.40 | $843.90 | $1,329.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.87 / $490.25 / $1,064.60
| Facility | | $354.87 | $490.25 | $1,064.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.40 / $810.04 / $1,124.19
| Professional | | $454.40 | $810.04 | $1,124.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.40 / $862.78 / $1,124.19
| Professional | | $454.40 | $862.78 | $1,124.19 |