- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.52 / $461.35 / $2,500.00
| Facility | | $306.52 | $461.35 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.27 / $391.16 / $462.39
| Professional | | $283.27 | $391.16 | $462.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.15 / $792.24 / $1,122.38
| Professional | | $612.15 | $792.24 | $1,122.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.42 / $811.71 / $1,400.87
| Professional | | $479.42 | $811.71 | $1,400.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.52 / $521.08 / $773.06
| Facility | | $306.52 | $521.08 | $773.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.53 / $846.35 / $2,318.23
| Professional | | $469.53 | $846.35 | $2,318.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.53 / $834.27 / $1,206.22
| Professional | | $469.53 | $834.27 | $1,206.22 |