- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $951.85 / $951.85 / $951.85
| Facility | | $951.85 | $951.85 | $951.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.85 / $951.85 / $1,522.91
| Professional | | $951.85 | $951.85 | $1,522.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $869.54 / $2,742.53 / $10,995.21
| Facility | | $869.54 | $2,742.53 | $10,995.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.82 / $1,455.62 / $2,127.44
| Professional | | $903.82 | $1,455.62 | $2,127.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.26 / $2,813.13 / $3,622.77
| Facility | | $2,312.26 | $2,813.13 | $3,622.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.51 / $1,932.94 / $1,932.94
| Professional | | $1,426.51 | $1,932.94 | $1,932.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.08 / $1,349.13 / $1,527.25
| Facility | | $1,260.08 | $1,349.13 | $1,527.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.86 / $984.86 / $2,417.63
| Professional | | $984.86 | $984.86 | $2,417.63 |
- 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
- $1,763.84 / $1,763.84 / $1,852.03
| Professional | | $1,763.84 | $1,763.84 | $1,852.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.99 / $1,150.99 / $1,150.99
| Professional | | $1,150.99 | $1,150.99 | $1,150.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,233.68 / $10,995.21 / $10,995.21
| Facility | | $4,233.68 | $10,995.21 | $10,995.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.98 / $1,164.50 / $2,127.44
| Professional | | $850.98 | $1,164.50 | $2,127.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.82 / $1,164.50 / $2,127.44
| Professional | | $903.82 | $1,164.50 | $2,127.44 |