- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.36 / $487.73 / $8,500.00
| Facility | | $308.36 | $487.73 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.57 / $427.58 / $487.73
| Professional | | $296.57 | $427.58 | $487.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.85 / $817.59 / $1,162.66
| Professional | | $633.85 | $817.59 | $1,162.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.84 / $914.23 / $1,296.23
| Professional | | $586.84 | $914.23 | $1,296.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.36 / $487.73 / $925.08
| Facility | | $308.36 | $487.73 | $925.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.06 / $880.16 / $3,659.12
| Professional | | $507.06 | $880.16 | $3,659.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.56 / $787.57 / $1,268.68
| Professional | | $476.56 | $787.57 | $1,268.68 |