- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.65 / $2,340.82 / $6,508.91
| Facility | | $801.65 | $2,340.82 | $6,508.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.21 / $881.82 / $1,135.68
| Professional | | $748.21 | $881.82 | $1,135.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.68 / $1,336.09 / $1,336.09
| Professional | | $1,135.68 | $1,336.09 | $1,336.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.32 / $3,039.61 / $5,953.30
| Facility | | $879.32 | $3,039.61 | $5,953.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.23 / $1,627.23 / $1,949.60
| Professional | | $1,627.23 | $1,627.23 | $1,949.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.73 / $6,346.43 / $6,346.43
| Facility | | $2,137.73 | $6,346.43 | $6,346.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,653.73 / $6,653.73 / $10,020.68
| Professional | | $6,653.73 | $6,653.73 | $10,020.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.65 / $1,336.09 / $1,971.92
| Facility | | $801.65 | $1,336.09 | $1,971.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,670.11
| Professional | | $1,336.09 | $1,336.09 | $1,670.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.46 / $1,670.11 / $4,676.31
| Professional | | $868.46 | $1,670.11 | $4,676.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.46 / $1,337.42 / $4,036.76
| Facility | | $868.46 | $1,337.42 | $4,036.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,603.31 / $2,338.16
| Professional | | $1,202.48 | $1,603.31 | $2,338.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.99 / $561.16 / $1,336.09
| Facility | | $480.99 | $561.16 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $561.16 / $855.10
| Professional | | $561.16 | $561.16 | $855.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.14 / $692.09 / $1,336.09
| Professional | | $423.14 | $692.09 | $1,336.09 |