- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.42 / $600.21 / $5,000.00
| Facility | | $428.42 | $600.21 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.25 / $503.02 / $606.79
| Professional | | $376.25 | $503.02 | $606.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.70 / $1,113.90 / $1,455.61
| Professional | | $860.70 | $1,113.90 | $1,455.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.47 / $1,138.40 / $1,837.59
| Professional | | $614.47 | $1,138.40 | $1,837.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.42 / $600.21 / $1,014.34
| Facility | | $428.42 | $600.21 | $1,014.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.36 / $1,101.08 / $3,232.96
| Professional | | $611.36 | $1,101.08 | $3,232.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.36 / $1,082.10 / $1,344.99
| Professional | | $611.36 | $1,082.10 | $1,344.99 |