- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,511.89
| Facility | | $1,737.80 | $1,737.80 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,698.24 / $2,041.74
| Professional | | $1,659.59 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,137.96 / $2,951.21
| Facility | | $776.25 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,698.24 / $3,019.95
| Professional | | $691.83 | $1,698.24 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $6,309.57
| Facility | | $2,290.87 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,288.25 / $7,079.46
| Facility | | $707.95 | $1,288.25 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $1,412.54
| Professional | | $794.33 | $977.24 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,884.03
| Professional | | $1,737.80 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,137.96 / $2,951.21
| Facility | | $776.25 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,698.24 / $3,019.95
| Professional | | $691.83 | $1,698.24 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,737.80
| Facility | | $794.33 | $933.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,737.80 / $2,398.83
| Professional | | $1,698.24 | $1,737.80 | $2,398.83 |