- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.28 / $525.28 / $8,500.00
| Facility | | $525.28 | $525.28 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.39 / $525.28 / $525.28
| Professional | | $475.39 | $525.28 | $525.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.09 / $1,110.44 / $1,331.17
| Professional | | $1,019.09 | $1,110.44 | $1,331.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.24 / $1,246.55 / $1,609.74
| Professional | | $637.24 | $1,246.55 | $1,609.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.28 / $697.81 / $1,575.84
| Facility | | $525.28 | $697.81 | $1,575.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.87 / $1,025.74 / $1,363.20
| Professional | | $543.87 | $1,025.74 | $1,363.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.93 / $1,092.52 / $1,363.20
| Professional | | $504.93 | $1,092.52 | $1,363.20 |