- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.65 / $587.37 / $5,000.00
| Facility | | $477.65 | $587.37 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $515.01 / $622.16
| Professional | | $461.36 | $515.01 | $622.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.12 / $1,190.23 / $1,468.87
| Professional | | $950.12 | $1,190.23 | $1,468.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.04 / $1,236.03 / $1,625.42
| Professional | | $613.04 | $1,236.03 | $1,625.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.65 / $692.37 / $1,021.01
| Facility | | $477.65 | $692.37 | $1,021.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.30 / $1,129.73 / $3,575.68
| Professional | | $593.30 | $1,129.73 | $3,575.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.30 / $1,077.53 / $1,360.13
| Professional | | $593.30 | $1,077.53 | $1,360.13 |