- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.36 / $3,142.80 / $5,000.00
| Facility | | $462.36 | $3,142.80 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.10 / $458.59 / $1,266.92
| Professional | | $401.10 | $458.59 | $1,266.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.86 / $1,039.40 / $1,218.74
| Professional | | $944.86 | $1,039.40 | $1,218.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.75 / $1,128.29 / $1,502.89
| Professional | | $564.75 | $1,128.29 | $1,502.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.36 / $778.36 / $4,525.16
| Facility | | $462.36 | $778.36 | $4,525.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.54 / $848.20 / $1,192.17
| Professional | | $491.54 | $848.20 | $1,192.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.54 / $829.39 / $997.91
| Professional | | $491.54 | $829.39 | $997.91 |