- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $447.47 / $447.47 / $8,500.00
| Facility | | $447.47 | $447.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.53 / $447.47 / $447.47
| Professional | | $418.53 | $447.47 | $447.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.49 / $977.27 / $1,171.26
| Professional | | $888.49 | $977.27 | $1,171.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.52 / $1,075.01 / $1,388.22
| Professional | | $563.52 | $1,075.01 | $1,388.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $447.47 / $563.88 / $1,342.41
| Facility | | $447.47 | $563.88 | $1,342.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.36 / $820.88 / $1,159.23
| Professional | | $467.36 | $820.88 | $1,159.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.36 / $860.84 / $1,159.23
| Professional | | $467.36 | $860.84 | $1,159.23 |