- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.32 / $386.27 / $2,000.00
| Facility | | $356.32 | $386.27 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.77 / $370.92 / $404.00
| Professional | | $315.77 | $370.92 | $404.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.29 / $859.08 / $1,013.12
| Professional | | $746.29 | $859.08 | $1,013.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.40 / $923.23 / $1,255.30
| Professional | | $424.40 | $923.23 | $1,255.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.32 / $458.91 / $692.21
| Facility | | $356.32 | $458.91 | $692.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.96 / $708.61 / $2,740.40
| Professional | | $400.96 | $708.61 | $2,740.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.04 / $708.61 / $1,018.34
| Professional | | $410.04 | $708.61 | $1,018.34 |