- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.62 / $3,008.52 / $3,008.52
| Facility | | $554.62 | $3,008.52 | $3,008.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.63 / $926.63 / $3,008.52
| Professional | | $926.63 | $926.63 | $3,008.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.04 / $608.73 / $710.86
| Facility | | $421.04 | $608.73 | $710.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.37 / $180.36 / $180.36
| Professional | | $144.37 | $180.36 | $180.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $811.64 / $8,877.36 / $21,354.13
| Facility | | $811.64 | $8,877.36 | $21,354.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.83 / $946.92 / $18,684.86
| Professional | | $777.83 | $946.92 | $18,684.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $439.64 / $526.28 / $892.47
| Facility | | $439.64 | $526.28 | $892.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.04 / $3,260.10 / $3,260.10
| Professional | | $785.04 | $3,260.10 | $3,260.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.08 / $405.82 / $676.37
| Professional | | $284.08 | $405.82 | $676.37 |