- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.06 / $501.65 / $5,000.00
| Facility | | $376.06 | $501.65 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.87 / $433.11 / $559.65
| Professional | | $353.87 | $433.11 | $559.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.44 / $1,044.97 / $1,366.92
| Professional | | $807.44 | $1,044.97 | $1,366.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.27 / $1,056.65 / $1,446.41
| Professional | | $517.27 | $1,056.65 | $1,446.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.06 / $668.36 / $942.32
| Facility | | $376.06 | $668.36 | $942.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.91 / $944.88 / $3,189.00
| Professional | | $513.91 | $944.88 | $3,189.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.91 / $968.49 / $1,309.58
| Professional | | $513.91 | $968.49 | $1,309.58 |