- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.41 / $570.28 / $2,500.00
| Facility | | $458.41 | $570.28 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.03 / $533.04 / $729.45
| Professional | | $436.03 | $533.04 | $729.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.16 / $1,089.51 / $1,344.54
| Professional | | $875.16 | $1,089.51 | $1,344.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.65 / $1,138.82 / $1,468.04
| Professional | | $637.65 | $1,138.82 | $1,468.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.41 / $612.05 / $954.85
| Facility | | $458.41 | $612.05 | $954.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.32 / $1,122.66 / $4,922.00
| Professional | | $580.32 | $1,122.66 | $4,922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.32 / $1,060.29 / $1,289.31
| Professional | | $580.32 | $1,060.29 | $1,289.31 |