- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.47 / $502.47 / $8,500.00
| Facility | | $502.47 | $502.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.24 / $502.47 / $502.47
| Professional | | $430.24 | $502.47 | $502.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.94 / $1,099.86 / $1,318.51
| Professional | | $1,004.94 | $1,099.86 | $1,318.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.60 / $1,127.29 / $1,455.73
| Professional | | $630.60 | $1,127.29 | $1,455.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.47 / $683.19 / $1,507.41
| Facility | | $502.47 | $683.19 | $1,507.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.20 / $921.78 / $1,284.14
| Professional | | $529.20 | $921.78 | $1,284.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.55 / $948.58 / $1,284.14
| Professional | | $548.55 | $948.58 | $1,284.14 |