- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $4,365.16
| Facility | | $758.58 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $1,621.81
| Professional | | $707.95 | $794.33 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,187.76
| Professional | | $1,348.96 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $2,137.96
| Facility | | $1,023.29 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,348.96 / $13,182.57
| Professional | | $724.44 | $1,348.96 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $1,819.70
| Professional | | $1,698.24 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,778.28
| Professional | | $1,698.24 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $1,548.82
| Professional | | $1,000.00 | $1,348.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,479.11 / $2,187.76
| Professional | | $870.96 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $1,862.09
| Professional | | $1,548.82 | $1,819.70 | $1,862.09 |