- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.41 / $432.05 / $2,000.00
| Facility | | $397.41 | $432.05 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.18 / $411.60 / $452.96
| Professional | | $354.18 | $411.60 | $452.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.11 / $961.07 / $1,130.67
| Professional | | $831.11 | $961.07 | $1,130.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.33 / $1,029.56 / $1,371.37
| Professional | | $515.33 | $1,029.56 | $1,371.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.41 / $515.13 / $775.15
| Facility | | $397.41 | $515.13 | $775.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.59 / $793.22 / $3,067.20
| Professional | | $448.59 | $793.22 | $3,067.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.59 / $760.37 / $986.90
| Professional | | $448.59 | $760.37 | $986.90 |