- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.45 / $755.45 / $755.45
| Facility | | $755.45 | $755.45 | $755.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.45 / $755.45 / $1,297.56
| Professional | | $755.45 | $755.45 | $1,297.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.96 / $4,617.68 / $9,394.98
| Facility | | $1,546.96 | $4,617.68 | $9,394.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.84 / $1,252.82 / $1,688.49
| Professional | | $778.84 | $1,252.82 | $1,688.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,825.18 / $2,231.25 / $2,862.44
| Facility | | $1,825.18 | $2,231.25 | $2,862.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.85 / $1,534.10 / $1,534.10
| Professional | | $1,180.85 | $1,534.10 | $1,534.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,260.83
| Facility | | $1,260.83 | $1,260.83 | $1,260.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $1,260.83 / $2,074.13
| Professional | | $920.41 | $1,260.83 | $2,074.13 |
- 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
- $1,399.89 / $1,399.89 / $1,469.88
| Professional | | $1,399.89 | $1,399.89 | $1,469.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.71 / $1,329.71 / $1,329.71
| Professional | | $1,329.71 | $1,329.71 | $1,329.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,632.20 / $9,394.98 / $9,394.98
| Facility | | $3,632.20 | $9,394.98 | $9,394.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.40 / $963.97 / $1,688.49
| Professional | | $675.40 | $963.97 | $1,688.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.08 / $963.97 / $1,645.34
| Professional | | $770.08 | $963.97 | $1,645.34 |