- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.42 / $671.42 / $2,290.00
| Facility | | $671.42 | $671.42 | $2,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.01 / $671.42 / $706.39
| Professional | | $639.01 | $671.42 | $706.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.62 / $1,110.53 / $1,935.51
| Facility | | $378.62 | $1,110.53 | $1,935.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.36 / $1,186.30 / $5,507.20
| Professional | | $538.36 | $1,186.30 | $5,507.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.96 / $862.11 / $1,363.78
| Facility | | $783.96 | $862.11 | $1,363.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.96 / $862.11 / $1,129.57
| Professional | | $783.96 | $862.11 | $1,129.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.64 / $1,186.30 / $1,665.52
| Professional | | $602.64 | $1,186.30 | $1,665.52 |