- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.68 / $507.68 / $8,500.00
| Facility | | $507.68 | $507.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.76 / $495.69 / $541.22
| Professional | | $448.76 | $495.69 | $541.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.15 / $1,148.61 / $1,346.81
| Professional | | $1,044.15 | $1,148.61 | $1,346.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.51 / $1,239.69 / $1,651.27
| Professional | | $620.51 | $1,239.69 | $1,651.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.68 / $642.08 / $870.32
| Facility | | $507.68 | $642.08 | $870.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.07 / $931.34 / $1,307.39
| Professional | | $542.07 | $931.34 | $1,307.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.07 / $914.46 / $1,192.55
| Professional | | $542.07 | $914.46 | $1,192.55 |