- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.11 / $2,619.36 / $3,090.85
| Facility | | $988.11 | $2,619.36 | $3,090.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.65 / $606.20 / $636.13
| Professional | | $396.65 | $606.20 | $636.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.74 / $583.74 / $583.74
| Professional | | $583.74 | $583.74 | $583.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.22 / $1,025.64 / $2,483.98
| Facility | | $710.22 | $1,025.64 | $2,483.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,607.24 / $3,607.24 / $3,607.24
| Professional | | $3,607.24 | $3,607.24 | $3,607.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.81 / $1,010.33 / $1,848.52
| Professional | | $785.81 | $1,010.33 | $1,848.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.78 / $3,090.85 / $3,090.85
| Facility | | $1,151.78 | $3,090.85 | $3,090.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.17 / $636.13 / $3,090.85
| Professional | | $491.17 | $636.13 | $3,090.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.61 / $1,122.58 / $1,496.78
| Professional | | $1,107.61 | $1,122.58 | $1,496.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.55 / $1,158.60 / $2,483.98
| Facility | | $728.55 | $1,158.60 | $2,483.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,607.24 / $3,607.24 / $3,607.24
| Professional | | $3,607.24 | $3,607.24 | $3,607.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.39 / $748.39 / $823.23
| Facility | | $748.39 | $748.39 | $823.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.39 / $748.39 / $823.23
| Professional | | $748.39 | $748.39 | $823.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $449.03 / $1,047.75
| Professional | | $314.32 | $449.03 | $1,047.75 |