- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.56 / $477.12 / $2,000.00
| Facility | | $443.56 | $477.12 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.78 / $443.56 / $495.81
| Professional | | $389.78 | $443.56 | $495.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.13 / $1,068.69 / $1,255.91
| Professional | | $925.13 | $1,068.69 | $1,255.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.04 / $1,144.33 / $1,524.25
| Professional | | $576.04 | $1,144.33 | $1,524.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.56 / $568.90 / $852.30
| Facility | | $443.56 | $568.90 | $852.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.15 / $885.30 / $3,404.88
| Professional | | $495.15 | $885.30 | $3,404.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.15 / $885.30 / $1,261.56
| Professional | | $495.15 | $885.30 | $1,261.56 |