- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,621.81
| Professional | | $851.14 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $1,778.28
| Facility | | $1,047.13 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $1,778.28
| Professional | | $758.58 | $1,445.44 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,162.28
| Facility | | $1,288.25 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,162.28
| Professional | | $1,288.25 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,698.24 / $2,238.72
| Facility | | $1,000.00 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,318.26 / $1,778.28
| Professional | | $79.43 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,071.52
| Facility | | $812.83 | $1,047.13 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $954.99
| Professional | | $741.31 | $831.76 | $954.99 |