- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $631.16 / $631.16 / $631.16
| Facility | | $631.16 | $631.16 | $631.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.16 / $702.09 / $1,268.04
| Professional | | $631.16 | $702.09 | $1,268.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $646.04 / $2,007.08 / $9,046.66
| Facility | | $646.04 | $2,007.08 | $9,046.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.69 / $1,110.52 / $1,410.68
| Professional | | $650.69 | $1,110.52 | $1,410.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,533.22 / $1,865.34 / $2,402.21
| Facility | | $1,533.22 | $1,865.34 | $2,402.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.49 / $1,281.70 / $1,281.70
| Professional | | $1,040.49 | $1,281.70 | $1,281.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.81 / $902.63 / $1,012.70
| Facility | | $834.81 | $902.63 | $1,012.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.92 / $902.63 / $2,232.75
| Professional | | $658.92 | $902.63 | $2,232.75 |
- 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
- $1,169.58 / $1,169.58 / $1,228.06
| Professional | | $1,169.58 | $1,169.58 | $1,228.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,909.88 / $9,046.66 / $9,046.66
| Facility | | $3,909.88 | $9,046.66 | $9,046.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.07 / $779.86 / $1,410.68
| Professional | | $597.07 | $779.86 | $1,410.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.34 / $1,110.52 / $1,410.68
| Professional | | $705.34 | $1,110.52 | $1,410.68 |