- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $999.86 / $999.86 / $999.86
| Facility | | $999.86 | $999.86 | $999.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.86 / $1,121.27 / $1,786.07
| Professional | | $999.86 | $1,121.27 | $1,786.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.40 / $3,849.14 / $12,133.56
| Facility | | $1,220.40 | $3,849.14 | $12,133.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.38 / $1,759.25 / $2,234.76
| Professional | | $1,117.38 | $1,759.25 | $2,234.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.88 / $2,955.02 / $3,805.50
| Facility | | $2,428.88 | $2,955.02 | $3,805.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.46 / $2,030.44 / $2,030.44
| Professional | | $1,498.46 | $2,030.44 | $2,030.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.65 / $1,665.63 / $1,665.63
| Facility | | $1,323.65 | $1,665.63 | $1,665.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $2,985.00
| Professional | | $1,215.91 | $1,665.63 | $2,985.00 |
- 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
- $1,852.81 / $1,852.81 / $1,945.45
| Professional | | $1,852.81 | $1,852.81 | $1,945.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.63 / $1,611.63 / $1,611.63
| Professional | | $1,611.63 | $1,611.63 | $1,611.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,226.89 / $12,133.56 / $12,133.56
| Facility | | $5,226.89 | $12,133.56 | $12,133.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.86 / $1,223.23 / $2,234.76
| Professional | | $945.86 | $1,223.23 | $2,234.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.86 / $1,223.23 / $2,234.76
| Professional | | $945.86 | $1,223.23 | $2,234.76 |