- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.92 / $521.70 / $5,000.00
| Facility | | $323.92 | $521.70 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.27 / $445.70 / $527.90
| Professional | | $282.27 | $445.70 | $527.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.73 / $862.87 / $1,275.73
| Professional | | $666.73 | $862.87 | $1,275.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.82 / $876.97 / $1,602.36
| Professional | | $494.82 | $876.97 | $1,602.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.92 / $521.70 / $884.23
| Facility | | $323.92 | $521.70 | $884.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.40 / $947.74 / $2,457.52
| Professional | | $533.40 | $947.74 | $2,457.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.40 / $947.74 / $1,364.14
| Professional | | $533.40 | $947.74 | $1,364.14 |