- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.85 / $423.31 / $5,000.00
| Facility | | $268.85 | $423.31 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.52 / $348.33 / $423.31
| Professional | | $247.52 | $348.33 | $423.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.30 / $773.32 / $1,007.15
| Professional | | $529.30 | $773.32 | $1,007.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.65 / $707.12 / $1,283.96
| Professional | | $417.65 | $707.12 | $1,283.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.85 / $456.46 / $697.46
| Facility | | $268.85 | $456.46 | $697.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.19 / $776.56 / $2,004.88
| Professional | | $430.19 | $776.56 | $2,004.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.19 / $757.13 / $946.42
| Professional | | $430.19 | $757.13 | $946.42 |