- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $553.60 / $553.60 / $553.60
| Facility | | $553.60 | $553.60 | $553.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.60 / $583.87 / $1,008.21
| Professional | | $553.60 | $583.87 | $1,008.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.61 / $3,575.44 / $6,045.06
| Facility | | $1,133.61 | $3,575.44 | $6,045.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.54 / $941.21 / $1,237.33
| Professional | | $578.54 | $941.21 | $1,237.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.45 / $1,636.12 / $2,107.01
| Facility | | $1,383.45 | $1,636.12 | $2,107.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.64 / $1,065.03 / $1,065.03
| Professional | | $912.64 | $1,065.03 | $1,065.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.63 / $724.63 / $931.26
| Facility | | $724.63 | $724.63 | $931.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.98 / $724.63 / $1,504.88
| Professional | | $528.98 | $724.63 | $1,504.88 |
- 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
- $1,025.84 / $1,025.84 / $1,077.14
| Professional | | $1,025.84 | $1,025.84 | $1,077.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.00 / $925.00 / $925.00
| Professional | | $925.00 | $925.00 | $925.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,635.26 / $6,045.06 / $6,045.06
| Facility | | $2,635.26 | $6,045.06 | $6,045.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.94 / $677.28 / $1,237.33
| Professional | | $494.94 | $677.28 | $1,237.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.29 / $677.28 / $1,267.04
| Professional | | $550.29 | $677.28 | $1,267.04 |