- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.50 / $663.50 / $663.50
| Facility | | $663.50 | $663.50 | $663.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.50 / $714.95 / $1,095.40
| Professional | | $663.50 | $714.95 | $1,095.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.89 / $2,526.98 / $9,402.01
| Facility | | $800.89 | $2,526.98 | $9,402.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.47 / $1,141.26 / $1,482.95
| Professional | | $672.47 | $1,141.26 | $1,482.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,611.78 / $1,960.91 / $2,525.28
| Facility | | $1,611.78 | $1,960.91 | $2,525.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.37 / $1,170.68 / $1,170.68
| Professional | | $994.37 | $1,170.68 | $1,170.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.37 / $1,116.13 / $1,149.77
| Facility | | $878.37 | $1,116.13 | $1,149.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.33 / $1,149.77 / $2,060.63
| Professional | | $839.33 | $1,149.77 | $2,060.63 |
- 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
- $1,229.50 / $1,229.50 / $1,290.98
| Professional | | $1,229.50 | $1,229.50 | $1,290.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.08 / $1,075.08 / $1,075.08
| Professional | | $1,075.08 | $1,075.08 | $1,075.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,164.45 / $9,402.01 / $9,402.01
| Facility | | $4,164.45 | $9,402.01 | $9,402.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.15 / $798.88 / $1,482.95
| Professional | | $578.15 | $798.88 | $1,482.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.69 / $811.73 / $1,482.95
| Professional | | $627.69 | $811.73 | $1,482.95 |