- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.52 / $973.52 / $973.52
| Facility | | $973.52 | $973.52 | $973.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.98 / $973.52 / $1,112.45
| Professional | | $827.98 | $973.52 | $1,112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.26 / $1,780.24 / $2,738.55
| Facility | | $1,212.26 | $1,780.24 | $2,738.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.60 / $1,237.00 / $1,237.00
| Professional | | $989.60 | $1,237.00 | $1,237.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,220.41 / $3,821.00 / $4,651.83
| Facility | | $2,220.41 | $3,821.00 | $4,651.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.61 / $1,407.56 / $1,523.52
| Professional | | $1,211.61 | $1,407.56 | $1,523.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,915.24 / $3,378.14 / $4,191.97
| Facility | | $1,915.24 | $3,378.14 | $4,191.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.63 / $1,199.63 / $1,279.59
| Professional | | $1,199.63 | $1,199.63 | $1,279.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.52 / $1,156.08 / $1,645.25
| Facility | | $973.52 | $1,156.08 | $1,645.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $5,826.31
| Professional | | $1,308.77 | $1,308.77 | $5,826.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $2,298.85
| Professional | | $1,308.77 | $1,308.77 | $2,298.85 |