- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.69 / $335.14 / $2,000.00
| Facility | | $298.69 | $335.14 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.60 / $311.06 / $356.08
| Professional | | $258.60 | $311.06 | $356.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.85 / $745.71 / $882.82
| Professional | | $633.85 | $745.71 | $882.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.91 / $790.73 / $1,111.83
| Professional | | $352.91 | $790.73 | $1,111.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.69 / $435.88 / $610.78
| Facility | | $298.69 | $435.88 | $610.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.74 / $614.80 / $2,323.92
| Professional | | $345.74 | $614.80 | $2,323.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.74 / $614.80 / $873.66
| Professional | | $345.74 | $614.80 | $873.66 |