- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $639.89 / $639.89 / $639.89
| Facility | | $639.89 | $639.89 | $639.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.89 / $639.89 / $1,155.14
| Professional | | $639.89 | $639.89 | $1,155.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.37 / $1,908.52 / $8,703.04
| Facility | | $635.37 | $1,908.52 | $8,703.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.70 / $1,056.42 / $1,430.21
| Professional | | $659.70 | $1,056.42 | $1,430.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.45 / $1,891.17 / $2,435.46
| Facility | | $1,554.45 | $1,891.17 | $2,435.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.98 / $1,299.45 / $1,299.45
| Professional | | $958.98 | $1,299.45 | $1,299.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.11 / $1,036.33 / $1,036.33
| Facility | | $847.11 | $1,036.33 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $1,036.33 / $1,857.38
| Professional | | $756.53 | $1,036.33 | $1,857.38 |
- 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
- $1,185.76 / $1,185.76 / $1,245.05
| Professional | | $1,185.76 | $1,185.76 | $1,245.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.05 / $873.05 / $873.05
| Professional | | $873.05 | $873.05 | $873.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,252.12 / $8,703.04 / $8,703.04
| Facility | | $3,252.12 | $8,703.04 | $8,703.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.08 / $782.84 / $1,430.21
| Professional | | $572.08 | $782.84 | $1,430.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.56 / $1,056.42 / $1,301.82
| Professional | | $685.56 | $1,056.42 | $1,301.82 |