- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.46 / $550.46 / $8,500.00
| Facility | | $550.46 | $550.46 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.41 / $550.46 / $879.66
| Professional | | $514.41 | $550.46 | $879.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.36 / $1,204.15 / $1,442.65
| Professional | | $1,094.36 | $1,204.15 | $1,442.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.81 / $1,319.25 / $1,703.62
| Professional | | $695.81 | $1,319.25 | $1,703.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.46 / $790.88 / $1,651.38
| Facility | | $550.46 | $790.88 | $1,651.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.02 / $1,009.82 / $1,427.48
| Professional | | $572.02 | $1,009.82 | $1,427.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.42 / $1,060.78 / $1,427.48
| Professional | | $583.42 | $1,060.78 | $1,427.48 |