- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.83 / $4,933.00 / $4,933.00
| Facility | | $394.83 | $4,933.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.26 / $375.09 / $394.83
| Professional | | $200.26 | $375.09 | $394.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,785.08 / $9,785.08 / $9,785.08
| Facility | | $9,785.08 | $9,785.08 | $9,785.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,295.83 / $10,176.48 / $13,209.86
| Professional | | $9,295.83 | $10,176.48 | $13,209.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.83 / $4,933.00 / $4,933.00
| Facility | | $394.83 | $4,933.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.83 / $512.30 / $671.79
| Professional | | $394.83 | $512.30 | $671.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,850.00 / $11,464.00 / $15,011.00
| Facility | | $6,850.00 | $11,464.00 | $15,011.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.13 / $501.93 / $721.12
| Professional | | $378.13 | $501.93 | $721.12 |