- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.75 / $558.71 / $5,000.00
| Facility | | $362.75 | $558.71 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.32 / $457.12 / $558.71
| Professional | | $313.32 | $457.12 | $558.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.08 / $953.91 / $1,361.93
| Professional | | $737.08 | $953.91 | $1,361.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.79 / $973.51 / $1,720.50
| Professional | | $566.79 | $973.51 | $1,720.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.75 / $574.60 / $949.59
| Facility | | $362.75 | $574.60 | $949.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.49 / $1,024.95 / $2,750.56
| Professional | | $569.49 | $1,024.95 | $2,750.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.49 / $1,011.78 / $1,205.85
| Professional | | $569.49 | $1,011.78 | $1,205.85 |