- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $2,290.87
| Professional | | $776.25 | $1,023.29 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $11,220.18
| Facility | | $1,584.89 | $1,819.70 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $1,819.70
| Professional | | $831.76 | $1,348.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,019.95
| Facility | | $1,905.46 | $2,290.87 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $1,548.82
| Professional | | $1,148.15 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $1,513.56
| Facility | | $1,023.29 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,513.56
| Professional | | $1,096.48 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,344.23
| Professional | | $1,548.82 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $11,220.18
| Facility | | $1,584.89 | $1,819.70 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $2,137.96
| Professional | | $831.76 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.41 / $1,318.26 / $2,398.83
| Facility | | $1.41 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,258.93 / $1,548.82
| Professional | | $758.58 | $1,258.93 | $1,548.82 |