- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.27 / $1,705.64 / $5,000.00
| Facility | | $355.27 | $1,705.64 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.55 / $422.77 / $542.86
| Professional | | $315.55 | $422.77 | $542.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.19 / $940.57 / $1,215.26
| Professional | | $729.19 | $940.57 | $1,215.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.64 / $1,008.35 / $1,365.71
| Professional | | $674.64 | $1,008.35 | $1,365.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.27 / $520.04 / $1,065.81
| Facility | | $355.27 | $520.04 | $1,065.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.74 / $929.81 / $3,847.36
| Professional | | $524.74 | $929.81 | $3,847.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.69 / $923.58 / $1,334.27
| Professional | | $544.69 | $923.58 | $1,334.27 |