- 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
- $575.44 / $724.44 / $2,570.40
| Professional | | $575.44 | $724.44 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,778.28 / $3,715.35
| Facility | | $758.58 | $1,778.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,454.71
| Professional | | $1,000.00 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $812.83
| Professional | | $691.83 | $691.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $870.96 / $2,818.38
| Facility | | $416.87 | $870.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $8,317.64
| Professional | | $588.84 | $645.65 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,000.00 / $1,047.13
| Facility | | $501.19 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $977.24
| Professional | | $588.84 | $645.65 | $977.24 |