- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.59 / $837.59 / $837.59
| Facility | | $837.59 | $837.59 | $837.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.84 / $837.59 / $3,001.16
| Professional | | $621.84 | $837.59 | $3,001.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,685.72 / $3,729.84 / $3,729.84
| Facility | | $1,685.72 | $3,729.84 | $3,729.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.00 / $1,345.87 / $7,032.99
| Professional | | $777.00 | $1,345.87 | $7,032.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.86 / $1,430.92 / $2,222.67
| Professional | | $869.86 | $1,430.92 | $2,222.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.74 / $883.74 / $883.74
| Facility | | $883.74 | $883.74 | $883.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.74 / $1,194.43 / $2,107.79
| Professional | | $759.74 | $1,194.43 | $2,107.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $901.61 / $901.61 / $901.61
| Facility | | $901.61 | $901.61 | $901.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.18 / $803.52 / $1,373.27
| Professional | | $436.18 | $803.52 | $1,373.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.12 / $1,845.93 / $2,383.62
| Professional | | $935.12 | $1,845.93 | $2,383.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.06 / $5,412.80 / $6,111.50
| Professional | | $1,202.06 | $5,412.80 | $6,111.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,685.72 / $3,729.84 / $3,729.84
| Facility | | $1,685.72 | $3,729.84 | $3,729.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.66 / $1,280.59 / $7,032.99
| Professional | | $811.66 | $1,280.59 | $7,032.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.61 / $1,110.27 / $2,153.55
| Professional | | $799.61 | $1,110.27 | $2,153.55 |