- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.26 / $615.26 / $615.26
| Facility | | $615.26 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.26 / $655.83 / $1,199.27
| Professional | | $615.26 | $655.83 | $1,199.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.35 / $2,566.09 / $7,374.61
| Facility | | $818.35 | $2,566.09 | $7,374.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.58 / $1,061.36 / $1,375.15
| Professional | | $687.58 | $1,061.36 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.62 / $1,818.38 / $2,341.73
| Facility | | $1,494.62 | $1,818.38 | $2,341.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.08 / $1,249.43 / $1,249.43
| Professional | | $922.08 | $1,249.43 | $1,249.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.51 / $1,034.99 / $1,105.99
| Facility | | $814.51 | $1,034.99 | $1,105.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.37 / $1,105.99 / $1,982.25
| Professional | | $807.37 | $1,105.99 | $1,982.25 |
- 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
- $1,140.13 / $1,140.13 / $1,197.14
| Professional | | $1,140.13 | $1,140.13 | $1,197.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.41 / $931.41 / $931.41
| Professional | | $931.41 | $931.41 | $931.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,470.73 / $7,374.61 / $7,374.61
| Facility | | $3,470.73 | $7,374.61 | $7,374.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.98 / $785.09 / $1,375.15
| Professional | | $573.98 | $785.09 | $1,375.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.59 / $752.72 / $1,375.15
| Professional | | $611.59 | $752.72 | $1,375.15 |