- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.65 / $601.65 / $601.65
| Facility | | $601.65 | $601.65 | $601.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.65 / $608.41 / $897.06
| Professional | | $601.65 | $608.41 | $897.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.72 / $3,560.55 / $6,758.11
| Facility | | $1,074.72 | $3,560.55 | $6,758.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.27 / $1,025.34 / $1,344.72
| Professional | | $572.27 | $1,025.34 | $1,344.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,503.52 / $1,778.12 / $2,289.89
| Facility | | $1,503.52 | $1,778.12 | $2,289.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.66 / $993.25 / $993.25
| Professional | | $901.66 | $993.25 | $993.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.49 / $1,014.49 / $1,014.49
| Facility | | $1,014.49 | $1,014.49 | $1,014.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.58 / $1,014.49 / $1,809.75
| Professional | | $740.58 | $1,014.49 | $1,809.75 |
- 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
- $1,114.88 / $1,114.88 / $1,170.61
| Professional | | $1,114.88 | $1,114.88 | $1,170.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.06 / $816.06 / $816.06
| Professional | | $816.06 | $816.06 | $816.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,168.65 / $6,758.11 / $6,758.11
| Facility | | $3,168.65 | $6,758.11 | $6,758.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.26 / $686.96 / $1,344.72
| Professional | | $524.26 | $686.96 | $1,344.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.16 / $686.96 / $1,263.33
| Professional | | $534.16 | $686.96 | $1,263.33 |