- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,235.94 / $3,235.94
| Facility | | $691.83 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $549.54 / $912.01
| Professional | | $446.68 | $549.54 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $2,089.30
| Facility | | $1,174.90 | $1,174.90 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $1,905.46
| Professional | | $724.44 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $794.33 / $1,000.00
| Professional | | $616.60 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,122.02
| Facility | | $645.65 | $794.33 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,000.00 / $1,905.46
| Facility | | $537.03 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $794.33 / $1,000.00
| Professional | | $79.43 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $2,818.38
| Facility | | $1,258.93 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $616.60 / $870.96
| Professional | | $575.44 | $616.60 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,148.15
| Facility | | $870.96 | $870.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $870.96
| Professional | | $302.00 | $302.00 | $870.96 |