- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.87 / $623.23 / $2,000.00
| Facility | | $347.87 | $623.23 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.82 / $471.51 / $647.87
| Professional | | $316.82 | $471.51 | $647.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.78 / $1,319.51 / $2,262.98
| Professional | | $854.78 | $1,319.51 | $2,262.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.26 / $1,293.81 / $2,707.86
| Professional | | $595.26 | $1,293.81 | $2,707.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.87 / $623.23 / $1,496.59
| Facility | | $347.87 | $623.23 | $1,496.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.12 / $1,143.32 / $3,619.88
| Professional | | $643.12 | $1,143.32 | $3,619.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.12 / $1,143.32 / $1,624.21
| Professional | | $643.12 | $1,143.32 | $1,624.21 |