- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.32 / $390.44 / $2,000.00
| Facility | | $358.32 | $390.44 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.68 / $373.15 / $412.55
| Professional | | $312.68 | $373.15 | $412.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.83 / $888.04 / $1,029.78
| Professional | | $754.83 | $888.04 | $1,029.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.86 / $936.73 / $1,247.73
| Professional | | $468.86 | $936.73 | $1,247.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.32 / $464.18 / $709.65
| Facility | | $358.32 | $464.18 | $709.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.56 / $716.26 / $2,769.76
| Professional | | $404.56 | $716.26 | $2,769.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.56 / $716.26 / $890.03
| Professional | | $404.56 | $716.26 | $890.03 |