- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.25 / $2,618.00 / $3,625.00
| Facility | | $643.25 | $2,618.00 | $3,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.13 / $643.25 / $953.05
| Professional | | $569.13 | $643.25 | $953.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.80 / $3,445.80 / $16,394.00
| Facility | | $896.80 | $3,445.80 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.15 / $1,183.89 / $4,506.80
| Professional | | $657.15 | $1,183.89 | $4,506.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.88 / $1,620.25 / $1,620.25
| Professional | | $605.88 | $1,620.25 | $1,620.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.00 / $652.29 / $3,103.98
| Facility | | $593.00 | $652.29 | $3,103.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.40 / $1,012.79 / $1,952.59
| Professional | | $516.40 | $1,012.79 | $1,952.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.00 / $1,338.42 / $6,679.00
| Facility | | $506.00 | $1,338.42 | $6,679.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.42 / $903.43 / $1,379.70
| Professional | | $711.42 | $903.43 | $1,379.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.00 / $1,516.03 / $1,957.63
| Professional | | $768.00 | $1,516.03 | $1,957.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.00 / $4,249.00 / $16,394.00
| Facility | | $1,061.00 | $4,249.00 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.25 / $1,212.33 / $4,506.80
| Professional | | $704.25 | $1,212.33 | $4,506.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.00 / $2,854.00 / $5,714.00
| Facility | | $1,061.00 | $2,854.00 | $5,714.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.89 / $975.07 / $2,115.57
| Professional | | $652.89 | $975.07 | $2,115.57 |