- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.16 / $538.73 / $5,000.00
| Facility | | $374.16 | $538.73 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.48 / $444.62 / $591.21
| Professional | | $320.48 | $444.62 | $591.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.31 / $1,039.03 / $1,329.60
| Professional | | $769.31 | $1,039.03 | $1,329.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.61 / $1,027.15 / $1,693.07
| Professional | | $514.61 | $1,027.15 | $1,693.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.16 / $538.73 / $934.38
| Facility | | $374.16 | $538.73 | $934.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.84 / $988.30 / $2,862.72
| Professional | | $547.84 | $988.30 | $2,862.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.84 / $966.87 / $1,162.74
| Professional | | $547.84 | $966.87 | $1,162.74 |