- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.63 / $551.35 / $2,000.00
| Facility | | $502.63 | $551.35 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.93 / $518.28 / $572.34
| Professional | | $451.93 | $518.28 | $572.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.46 / $1,229.96 / $1,431.56
| Professional | | $1,045.46 | $1,229.96 | $1,431.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.37 / $1,286.95 / $1,776.41
| Professional | | $643.37 | $1,286.95 | $1,776.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.63 / $643.52 / $981.13
| Facility | | $502.63 | $643.52 | $981.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $1,011.45 / $3,840.24
| Professional | | $573.46 | $1,011.45 | $3,840.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $1,011.45 / $1,261.60
| Professional | | $573.46 | $1,011.45 | $1,261.60 |