- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.40 / $577.40 / $8,500.00
| Facility | | $577.40 | $577.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.41 / $572.67 / $662.01
| Professional | | $527.41 | $572.67 | $662.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.70 / $1,369.23 / $1,605.49
| Professional | | $1,244.70 | $1,369.23 | $1,605.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.35 / $1,437.16 / $1,914.30
| Professional | | $719.35 | $1,437.16 | $1,914.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.40 / $630.28 / $1,017.52
| Facility | | $577.40 | $630.28 | $1,017.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.96 / $1,093.56 / $1,480.66
| Professional | | $627.96 | $1,093.56 | $1,480.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.96 / $1,048.28 / $1,325.42
| Professional | | $627.96 | $1,048.28 | $1,325.42 |