- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $707.95 / $1,047.13
| Professional | | $501.19 | $707.95 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $1,698.24
| Facility | | $1,513.56 | $1,584.89 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $1,380.38
| Professional | | $537.03 | $537.03 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $933.25 / $3,162.28
| Facility | | $380.19 | $933.25 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $630.96 / $10,000.00
| Professional | | $389.05 | $630.96 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,000.00 / $1,000.00
| Facility | | $501.19 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $616.60 / $851.14
| Professional | | $416.87 | $616.60 | $851.14 |