- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.70 / $621.51 / $2,000.00
| Facility | | $392.70 | $621.51 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.58 / $440.22 / $634.29
| Professional | | $319.58 | $440.22 | $634.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.39 / $1,050.08 / $1,543.48
| Professional | | $811.39 | $1,050.08 | $1,543.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.91 / $1,059.33 / $1,627.88
| Professional | | $543.91 | $1,059.33 | $1,627.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.70 / $621.51 / $1,060.15
| Facility | | $392.70 | $621.51 | $1,060.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.38 / $1,005.64 / $2,984.48
| Professional | | $603.38 | $1,005.64 | $2,984.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.38 / $1,005.64 / $1,404.55
| Professional | | $603.38 | $1,005.64 | $1,404.55 |