- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $859.60 / $859.60 / $859.60
| Facility | | $859.60 | $859.60 | $859.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.96 / $859.60 / $2,709.64
| Professional | | $735.96 | $859.60 | $2,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.73 / $1,986.71 / $2,483.38
| Professional | | $1,807.73 | $1,986.71 | $2,483.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.42 / $1,386.14 / $2,016.53
| Facility | | $1,052.42 | $1,386.14 | $2,016.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.45 / $1,548.83 / $7,993.06
| Professional | | $845.45 | $1,548.83 | $7,993.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.53 / $2,078.29 / $2,893.86
| Facility | | $1,099.53 | $2,078.29 | $2,893.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.48 / $1,807.73 / $2,534.10
| Professional | | $1,282.48 | $1,807.73 | $2,534.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.11 / $1,440.48 / $1,857.90
| Professional | | $970.11 | $1,440.48 | $1,857.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.45 / $1,548.83 / $2,409.29
| Professional | | $845.45 | $1,548.83 | $2,409.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.10 / $2,168.40 / $2,255.10
| Professional | | $1,843.10 | $2,168.40 | $2,255.10 |