- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.45 / $1,615.00 / $6,953.60
| Facility | | $946.45 | $1,615.00 | $6,953.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.45 / $946.45 / $1,329.10
| Professional | | $946.45 | $946.45 | $1,329.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.03 / $2,117.30 / $2,849.57
| Professional | | $1,325.03 | $2,117.30 | $2,849.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.31 / $1,618.43 / $2,828.45
| Professional | | $1,213.31 | $1,618.43 | $2,828.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.30 / $1,250.61 / $1,861.23
| Facility | | $900.30 | $1,250.61 | $1,861.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.61 / $1,250.61 / $1,250.61
| Professional | | $1,250.61 | $1,250.61 | $1,250.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.00 / $3,906.00 / $6,388.00
| Facility | | $1,064.00 | $3,906.00 | $6,388.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.37 / $1,514.78 / $2,650.26
| Professional | | $979.37 | $1,514.78 | $2,650.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $9,784.61 / $11,807.51
| Facility | | $55.00 | $9,784.61 | $11,807.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,754.24 / $8,177.70 / $8,177.70
| Professional | | $6,754.24 | $8,177.70 | $8,177.70 |