- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.50 / $775.50 / $775.50
| Facility | | $775.50 | $775.50 | $775.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.50 / $775.50 / $1,246.01
| Professional | | $775.50 | $775.50 | $1,246.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.01 / $5,056.01 / $10,110.42
| Facility | | $1,588.01 | $5,056.01 | $10,110.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.14 / $1,295.67 / $1,733.29
| Professional | | $723.14 | $1,295.67 | $1,733.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.98 / $2,291.94 / $2,951.59
| Facility | | $1,937.98 | $2,291.94 | $2,951.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.43 / $1,368.29 / $1,368.29
| Professional | | $1,278.43 | $1,368.29 | $1,368.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.36 / $1,030.36 / $1,030.36
| Facility | | $1,030.36 | $1,030.36 | $1,030.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.17 / $752.17 / $1,893.75
| Professional | | $752.17 | $752.17 | $1,893.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.05 / $1,437.05 / $1,508.90
| Professional | | $1,437.05 | $1,437.05 | $1,508.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.95 / $1,163.95 / $1,163.95
| Professional | | $1,163.95 | $1,163.95 | $1,163.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,469.88 / $10,110.42 / $10,110.42
| Facility | | $3,469.88 | $10,110.42 | $10,110.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.68 / $885.47 / $1,733.29
| Professional | | $663.68 | $885.47 | $1,733.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.99 / $948.74 / $1,700.18
| Professional | | $674.99 | $948.74 | $1,700.18 |