- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.43 / $460.38 / $2,000.00
| Facility | | $417.43 | $460.38 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.09 / $434.70 / $482.83
| Professional | | $367.09 | $434.70 | $482.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.82 / $1,024.48 / $1,205.27
| Professional | | $875.82 | $1,024.48 | $1,205.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.78 / $1,084.41 / $1,444.44
| Professional | | $542.78 | $1,084.41 | $1,444.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.43 / $538.58 / $829.71
| Facility | | $417.43 | $538.58 | $829.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.10 / $835.70 / $3,220.08
| Professional | | $477.10 | $835.70 | $3,220.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.10 / $835.70 / $1,049.61
| Professional | | $477.10 | $835.70 | $1,049.61 |