- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.45 / $502.45 / $8,500.00
| Facility | | $502.45 | $502.45 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.68 / $490.36 / $535.91
| Professional | | $481.68 | $490.36 | $535.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.63 / $1,137.04 / $1,333.24
| Professional | | $1,033.63 | $1,137.04 | $1,333.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.16 / $1,227.03 / $1,634.41
| Professional | | $614.16 | $1,227.03 | $1,634.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.45 / $635.61 / $861.28
| Facility | | $502.45 | $635.61 | $861.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.65 / $921.74 / $1,293.76
| Professional | | $536.65 | $921.74 | $1,293.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.65 / $889.68 / $1,084.44
| Professional | | $536.65 | $889.68 | $1,084.44 |