- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $955.20 / $955.20 / $955.20
| Facility | | $955.20 | $955.20 | $955.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.20 / $955.20 / $1,230.95
| Professional | | $955.20 | $955.20 | $1,230.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,169.55 / $3,688.76 / $10,896.03
| Facility | | $1,169.55 | $3,688.76 | $10,896.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.39 / $1,361.26 / $2,134.92
| Professional | | $840.39 | $1,361.26 | $2,134.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,320.38 / $2,823.01 / $3,635.51
| Facility | | $2,320.38 | $2,823.01 | $3,635.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.52 / $1,685.36 / $1,685.36
| Professional | | $1,431.52 | $1,685.36 | $1,685.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,264.51 / $1,532.61
| Facility | | $1,212.63 | $1,264.51 | $1,532.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.22 / $1,212.63 / $2,173.13
| Professional | | $885.22 | $1,212.63 | $2,173.13 |
- 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
- $1,770.03 / $1,770.03 / $1,858.53
| Professional | | $1,770.03 | $1,770.03 | $1,858.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.14 / $1,238.14 / $1,238.14
| Professional | | $1,238.14 | $1,238.14 | $1,238.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,271.89 / $10,896.03 / $10,896.03
| Facility | | $4,271.89 | $10,896.03 | $10,896.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.10 / $1,090.65 / $2,134.92
| Professional | | $727.10 | $1,090.65 | $2,134.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.75 / $1,090.65 / $1,770.03
| Professional | | $775.75 | $1,090.65 | $1,770.03 |