- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.65 / $850.65 / $850.65
| Facility | | $850.65 | $850.65 | $850.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.65 / $897.22 / $1,575.69
| Professional | | $850.65 | $897.22 | $1,575.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.70 / $3,528.38 / $10,188.70
| Facility | | $1,118.70 | $3,528.38 | $10,188.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.00 / $1,442.35 / $1,901.24
| Professional | | $936.00 | $1,442.35 | $1,901.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,066.40 / $2,514.02 / $3,237.58
| Facility | | $2,066.40 | $2,514.02 | $3,237.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.83 / $1,727.41 / $1,727.41
| Professional | | $1,274.83 | $1,727.41 | $1,727.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.11 / $1,430.93 / $1,576.65
| Facility | | $1,125.11 | $1,430.93 | $1,576.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.95 / $1,576.65 / $2,825.63
| Professional | | $1,150.95 | $1,576.65 | $2,825.63 |
- 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
- $1,576.30 / $1,576.30 / $1,655.12
| Professional | | $1,576.30 | $1,576.30 | $1,655.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.21 / $1,274.21 / $1,274.21
| Professional | | $1,274.21 | $1,274.21 | $1,274.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.70 / $10,188.70 / $10,188.70
| Facility | | $4,947.70 | $10,188.70 | $10,188.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.00 / $1,040.68 / $1,901.24
| Professional | | $780.00 | $1,040.68 | $1,901.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.70 / $1,040.68 / $1,880.80
| Professional | | $804.70 | $1,040.68 | $1,880.80 |