- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.33 / $497.58 / $5,000.00
| Facility | | $350.33 | $497.58 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.73 / $432.29 / $563.83
| Professional | | $309.73 | $432.29 | $563.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.27 / $906.27 / $1,195.33
| Professional | | $700.27 | $906.27 | $1,195.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.58 / $935.16 / $1,509.53
| Professional | | $524.58 | $935.16 | $1,509.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.33 / $532.10 / $833.26
| Facility | | $350.33 | $532.10 | $833.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.06 / $912.81 / $2,630.72
| Professional | | $507.06 | $912.81 | $2,630.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.06 / $897.50 / $1,073.93
| Professional | | $507.06 | $897.50 | $1,073.93 |