- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $804.07 / $804.07 / $804.07
| Facility | | $804.07 | $804.07 | $804.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.07 / $804.07 / $1,373.42
| Professional | | $804.07 | $804.07 | $1,373.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.15 / $3,047.24 / $8,561.92
| Facility | | $966.15 | $3,047.24 | $8,561.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.25 / $1,289.81 / $1,797.15
| Professional | | $813.25 | $1,289.81 | $1,797.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.28 / $2,376.39 / $3,060.34
| Facility | | $1,953.28 | $2,376.39 | $3,060.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.03 / $1,632.85 / $1,632.85
| Professional | | $1,205.03 | $1,632.85 | $1,632.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,064.45 / $1,290.11
| Facility | | $1,018.60 | $1,064.45 | $1,290.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $2,056.13
| Professional | | $743.58 | $743.58 | $2,056.13 |
- 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
- $1,490.00 / $1,490.00 / $1,564.50
| Professional | | $1,490.00 | $1,490.00 | $1,564.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.69 / $1,286.69 / $1,286.69
| Professional | | $1,286.69 | $1,286.69 | $1,286.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.39 / $8,561.92 / $8,561.92
| Facility | | $3,600.39 | $8,561.92 | $8,561.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.86 / $983.70 / $1,797.15
| Professional | | $718.86 | $983.70 | $1,797.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.25 / $1,025.99 / $1,635.82
| Professional | | $799.25 | $1,025.99 | $1,635.82 |