- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.95 / $722.95 / $722.95
| Facility | | $722.95 | $722.95 | $722.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.95 / $740.20 / $1,390.89
| Professional | | $722.95 | $740.20 | $1,390.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.89 / $2,405.71 / $10,479.26
| Facility | | $800.89 | $2,405.71 | $10,479.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.75 / $1,272.03 / $1,615.84
| Professional | | $762.75 | $1,272.03 | $1,615.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,756.21 / $2,136.64 / $2,751.58
| Facility | | $1,756.21 | $2,136.64 | $2,751.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.81 / $1,468.11 / $1,468.11
| Professional | | $1,191.81 | $1,468.11 | $1,468.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.07 / $1,216.13 / $1,427.14
| Facility | | $957.07 | $1,216.13 | $1,427.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.81 / $1,427.14 / $2,557.50
| Professional | | $1,041.81 | $1,427.14 | $2,557.50 |
- 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
- $1,339.68 / $1,339.68 / $1,406.66
| Professional | | $1,339.68 | $1,339.68 | $1,406.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.23 / $1,051.23 / $1,051.23
| Professional | | $1,051.23 | $1,051.23 | $1,051.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,478.50 / $10,479.26 / $10,479.26
| Facility | | $4,478.50 | $10,479.26 | $10,479.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.90 / $893.29 / $1,615.84
| Professional | | $683.90 | $893.29 | $1,615.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.62 / $884.46 / $1,615.84
| Professional | | $718.62 | $884.46 | $1,615.84 |