- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.49 / $583.49 / $8,500.00
| Facility | | $583.49 | $583.49 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.73 / $558.36 / $583.49
| Professional | | $510.73 | $558.36 | $583.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.75 / $1,312.08 / $1,538.48
| Professional | | $1,192.75 | $1,312.08 | $1,538.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.80 / $1,492.02 / $1,987.37
| Professional | | $746.80 | $1,492.02 | $1,987.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.49 / $733.46 / $1,029.76
| Facility | | $583.49 | $733.46 | $1,029.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.86 / $1,077.13 / $1,514.54
| Professional | | $604.86 | $1,077.13 | $1,514.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.86 / $1,070.59 / $1,393.14
| Professional | | $604.86 | $1,070.59 | $1,393.14 |