- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $474.91 / $4,112.00 / $4,933.00
| Facility | | $474.91 | $4,112.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.91 / $474.91 / $543.11
| Professional | | $375.91 | $474.91 | $543.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,679.39 / $6,679.39 / $6,679.39
| Facility | | $6,679.39 | $6,679.39 | $6,679.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,345.42 / $7,013.36 / $8,349.24
| Professional | | $6,345.42 | $7,013.36 | $8,349.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.53 / $4,112.00 / $4,933.00
| Facility | | $519.53 | $4,112.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.91 / $519.53 / $649.41
| Professional | | $474.91 | $519.53 | $649.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.00 / $5,048.00 / $7,355.00
| Facility | | $1,450.00 | $5,048.00 | $7,355.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.71 / $613.09 / $802.86
| Professional | | $508.71 | $613.09 | $802.86 |