- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.16 / $467.48 / $2,500.00
| Facility | | $306.16 | $467.48 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.18 / $421.32 / $585.52
| Professional | | $300.18 | $421.32 | $585.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.30 / $809.26 / $1,150.56
| Professional | | $625.30 | $809.26 | $1,150.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.31 / $829.59 / $1,232.76
| Professional | | $485.31 | $829.59 | $1,232.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.16 / $467.48 / $802.87
| Facility | | $306.16 | $467.48 | $802.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.66 / $857.59 / $2,336.08
| Professional | | $475.66 | $857.59 | $2,336.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.66 / $843.35 / $1,046.45
| Professional | | $475.66 | $843.35 | $1,046.45 |