- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $2,458.08 / $3,438.30
| Facility | | $1,263.53 | $2,458.08 | $3,438.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.93 / $972.92 / $1,099.27
| Professional | | $833.93 | $972.92 | $1,099.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $2,294.59 / $2,868.24
| Professional | | $1,516.24 | $2,294.59 | $2,868.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.00 / $1,705.77 / $2,286.98
| Professional | | $1,074.00 | $1,705.77 | $2,286.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,642.59 / $3,396.88
| Facility | | $1,263.53 | $1,642.59 | $3,396.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.12 / $804.24 / $4,935.68
| Professional | | $758.12 | $804.24 | $4,935.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.24 / $2,211.17 / $3,234.64
| Facility | | $1,516.24 | $2,211.17 | $3,234.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $2,486.63 / $3,396.88
| Professional | | $1,516.24 | $2,486.63 | $3,396.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $2,255.40
| Professional | | $1,263.53 | $1,263.53 | $2,255.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.12 / $758.12 / $4,077.54
| Professional | | $758.12 | $758.12 | $4,077.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,263.53
| Professional | | $1,263.53 | $1,263.53 | $1,263.53 |