- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $977.24 / $1,659.59
| Facility | | $575.44 | $977.24 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $812.83
| Professional | | $575.44 | $575.44 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $794.33 / $1,737.80
| Facility | | $602.56 | $794.33 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $776.25
| Professional | | $575.44 | $575.44 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $575.44 / $741.31
| Facility | | $549.54 | $575.44 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $758.58
| Professional | | $575.44 | $602.56 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $1,000.00
| Facility | | $562.34 | $575.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $691.83
| Professional | | $575.44 | $575.44 | $691.83 |