- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.31 / $752.31 / $752.31
| Facility | | $752.31 | $752.31 | $752.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.31 / $752.31 / $1,003.72
| Professional | | $752.31 | $752.31 | $1,003.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.35 / $2,611.23 / $9,097.53
| Facility | | $818.35 | $2,611.23 | $9,097.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.59 / $1,136.57 / $1,681.47
| Professional | | $672.59 | $1,136.57 | $1,681.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,827.54 / $2,223.42 / $2,863.34
| Facility | | $1,827.54 | $2,223.42 | $2,863.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.58 / $995.93 / $1,207.08
| Facility | | $897.58 | $995.93 | $1,207.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.23 / $655.23 / $1,845.75
| Professional | | $655.23 | $655.23 | $1,845.75 |
- 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
- $1,394.09 / $1,394.09 / $1,463.79
| Professional | | $1,394.09 | $1,394.09 | $1,463.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.74 / $933.74 / $933.74
| Professional | | $933.74 | $933.74 | $933.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,232.02 / $9,097.53 / $9,097.53
| Facility | | $3,232.02 | $9,097.53 | $9,097.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.19 / $859.00 / $1,681.47
| Professional | | $597.19 | $859.00 | $1,681.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.27 / $957.27 / $957.27
| Facility | | $957.27 | $957.27 | $957.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.70 / $859.00 / $1,436.45
| Professional | | $647.70 | $859.00 | $1,436.45 |