- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $998.46 / $998.46 / $998.46
| Facility | | $998.46 | $998.46 | $998.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.46 / $1,110.67 / $1,783.56
| Professional | | $998.46 | $1,110.67 | $1,783.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,155.00 / $3,642.87 / $11,959.60
| Facility | | $1,155.00 | $3,642.87 | $11,959.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.82 / $1,756.79 / $2,231.63
| Professional | | $1,115.82 | $1,756.79 | $2,231.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.48 / $2,950.88 / $3,800.18
| Facility | | $2,425.48 | $2,950.88 | $3,800.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.00 / $2,027.59 / $2,027.59
| Professional | | $1,646.00 | $2,027.59 | $2,027.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.62 / $1,679.59 / $1,800.00
| Facility | | $1,320.62 | $1,679.59 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,800.00 / $3,430.50
| Professional | | $1,314.00 | $1,800.00 | $3,430.50 |
- 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
- $1,850.22 / $1,850.22 / $1,942.73
| Professional | | $1,850.22 | $1,850.22 | $1,942.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.62 / $1,565.62 / $1,565.62
| Professional | | $1,565.62 | $1,565.62 | $1,565.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,006.69 / $11,959.60 / $11,959.60
| Facility | | $6,006.69 | $11,959.60 | $11,959.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.53 / $1,233.71 / $2,231.63
| Professional | | $944.53 | $1,233.71 | $2,231.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.65 / $1,221.52 / $2,231.63
| Professional | | $892.65 | $1,221.52 | $2,231.63 |