- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.35 / $635.35 / $635.35
| Facility | | $635.35 | $635.35 | $635.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.35 / $650.51 / $1,222.35
| Professional | | $635.35 | $650.51 | $1,222.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.03 / $3,883.57 / $9,209.54
| Facility | | $1,301.03 | $3,883.57 | $9,209.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.03 / $1,117.90 / $1,420.05
| Professional | | $710.03 | $1,117.90 | $1,420.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.89 / $1,896.91 / $2,626.67
| Facility | | $1,630.89 | $1,896.91 | $2,626.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.12 / $1,290.23 / $1,290.23
| Professional | | $993.12 | $1,290.23 | $1,290.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.63 / $908.63 / $908.63
| Facility | | $908.63 | $908.63 | $908.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.30 / $908.63 / $1,945.88
| Professional | | $663.30 | $908.63 | $1,945.88 |
- 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
- $1,177.35 / $1,177.35 / $1,236.23
| Professional | | $1,177.35 | $1,177.35 | $1,236.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.98 / $1,029.98 / $1,029.98
| Professional | | $1,029.98 | $1,029.98 | $1,029.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,407.64 / $9,209.54 / $9,209.54
| Facility | | $3,407.64 | $9,209.54 | $9,209.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.03 / $810.71 / $1,420.05
| Professional | | $601.03 | $810.71 | $1,420.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,938.85 / $1,938.85 / $1,938.85
| Facility | | $1,938.85 | $1,938.85 | $1,938.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.02 / $852.03 / $1,476.11
| Professional | | $655.02 | $852.03 | $1,476.11 |