- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.11 / $491.98 / $5,000.00
| Facility | | $319.11 | $491.98 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.54 / $431.63 / $586.91
| Professional | | $287.54 | $431.63 | $586.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.37 / $837.76 / $1,207.76
| Professional | | $644.37 | $837.76 | $1,207.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.42 / $933.85 / $1,277.46
| Professional | | $492.42 | $933.85 | $1,277.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.11 / $491.98 / $832.41
| Facility | | $319.11 | $491.98 | $832.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.65 / $897.25 / $2,424.71
| Professional | | $501.65 | $897.25 | $2,424.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.65 / $887.92 / $1,103.63
| Professional | | $501.65 | $887.92 | $1,103.63 |