- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $538.12 / $570.97 / $2,000.00
| Facility | | $538.12 | $570.97 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.11 / $555.01 / $591.65
| Professional | | $482.11 | $555.01 | $591.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.10 / $1,288.24 / $1,481.31
| Professional | | $1,119.10 | $1,288.24 | $1,481.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.69 / $1,376.40 / $1,833.37
| Professional | | $654.69 | $1,376.40 | $1,833.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $538.12 / $688.18 / $1,013.26
| Facility | | $538.12 | $688.18 | $1,013.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.76 / $1,047.44 / $4,113.76
| Professional | | $594.76 | $1,047.44 | $4,113.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.76 / $1,047.44 / $1,308.47
| Professional | | $594.76 | $1,047.44 | $1,308.47 |