- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $399.75 / $531.11 / $2,000.00
| Facility | | $399.75 | $531.11 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.64 / $452.07 / $583.17
| Professional | | $355.64 | $452.07 | $583.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.15 / $1,037.25 / $1,339.56
| Professional | | $804.15 | $1,037.25 | $1,339.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.30 / $1,023.38 / $1,399.93
| Professional | | $558.30 | $1,023.38 | $1,399.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $399.75 / $677.90 / $911.65
| Facility | | $399.75 | $677.90 | $911.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.84 / $974.32 / $2,988.96
| Professional | | $547.84 | $974.32 | $2,988.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.84 / $969.68 / $1,205.25
| Professional | | $547.84 | $969.68 | $1,205.25 |