- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.13 / $417.13 / $417.13
| Facility | | $417.13 | $417.13 | $417.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.81 / $417.13 / $463.02
| Professional | | $277.81 | $417.13 | $463.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,640.30 / $13,265.70 / $23,333.99
| Facility | | $7,640.30 | $13,265.70 | $23,333.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,899.61 / $6,899.61 / $15,370.24
| Professional | | $6,899.61 | $6,899.61 | $15,370.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.13 / $716.44 / $3,053.00
| Facility | | $417.13 | $716.44 | $3,053.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.92 / $967.50 / $3,180.32
| Professional | | $508.92 | $967.50 | $3,180.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.79 / $911.07 / $1,768.06
| Professional | | $486.79 | $911.07 | $1,768.06 |