- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.85 / $2,098.50 / $2,098.50
| Facility | | $653.85 | $2,098.50 | $2,098.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.08 / $2,098.50 / $2,856.27
| Professional | | $782.08 | $2,098.50 | $2,856.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.02 / $1,588.55 / $9,011.04
| Facility | | $148.02 | $1,588.55 | $9,011.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.88 / $1,836.36 / $6,869.73
| Professional | | $484.88 | $1,836.36 | $6,869.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.63 / $1,725.87 / $3,126.58
| Facility | | $1,250.63 | $1,725.87 | $3,126.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.74 / $5,546.65 / $13,425.04
| Facility | | $1,162.74 | $5,546.65 | $13,425.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.68 / $803.65 / $1,395.66
| Professional | | $443.68 | $803.65 | $1,395.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.91 / $1,089.98 / $8,090.00
| Facility | | $606.91 | $1,089.98 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.02 / $788.98 / $1,365.25
| Professional | | $61.02 | $788.98 | $1,365.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.16 / $1,079.84 / $1,425.14
| Professional | | $536.16 | $1,079.84 | $1,425.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.97 / $9,011.04 / $9,011.04
| Facility | | $903.97 | $9,011.04 | $9,011.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.59 / $2,465.31 / $6,869.73
| Professional | | $641.59 | $2,465.31 | $6,869.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.98 / $2,018.14 / $5,480.58
| Professional | | $613.98 | $2,018.14 | $5,480.58 |