- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $3,090.30 / $4,365.16
| Facility | | $562.34 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $1,000.00
| Professional | | $524.81 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $1,659.59
| Professional | | $1,000.00 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,318.26
| Facility | | $691.83 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $4,466.84
| Professional | | $501.19 | $831.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,258.93
| Professional | | $1,071.52 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,096.48
| Professional | | $1,071.52 | $1,071.52 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,122.02
| Professional | | $602.56 | $891.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $977.24 / $1,548.82
| Professional | | $537.03 | $977.24 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,380.38
| Professional | | $1,122.02 | $1,318.26 | $1,380.38 |