- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $1,288.25
| Professional | | $645.65 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $2,290.87
| Facility | | $1,412.54 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $1,584.89
| Professional | | $1,122.02 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $6,918.31
| Facility | | $891.25 | $3,235.94 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,995.26 / $2,630.27
| Professional | | $645.65 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $1,737.80
| Facility | | $691.83 | $1,122.02 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $2,398.83
| Professional | | $1,258.93 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,380.38 / $7,413.10
| Facility | | $707.95 | $1,380.38 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,659.59
| Professional | | $645.65 | $812.83 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $70.79 / $1,000.00
| Professional | | $54.95 | $70.79 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $4,365.16
| Professional | | $1,412.54 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,818.38 / $8,128.31
| Facility | | $891.25 | $2,818.38 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,288.25 / $8,128.31
| Professional | | $645.65 | $1,288.25 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $2,238.72
| Facility | | $630.96 | $794.33 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $691.83 / $1,174.90
| Professional | | $537.03 | $691.83 | $1,174.90 |