- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.96 / $769.96 / $769.96
| Facility | | $769.96 | $769.96 | $769.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.96 / $856.49 / $1,469.69
| Professional | | $769.96 | $856.49 | $1,469.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.94 / $2,630.25 / $11,160.65
| Facility | | $833.94 | $2,630.25 | $11,160.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.94 / $1,354.74 / $1,720.91
| Professional | | $833.94 | $1,354.74 | $1,720.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.41 / $2,275.57 / $2,930.50
| Facility | | $1,870.41 | $2,275.57 | $2,930.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.91 / $1,563.57 / $1,563.57
| Professional | | $1,153.91 | $1,563.57 | $1,563.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.30 / $1,295.21 / $1,498.90
| Facility | | $1,019.30 | $1,295.21 | $1,498.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.20 / $1,498.90 / $2,686.13
| Professional | | $1,094.20 | $1,498.90 | $2,686.13 |
- 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
- $1,426.78 / $1,426.78 / $1,498.12
| Professional | | $1,426.78 | $1,426.78 | $1,498.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.87 / $1,353.87 / $1,353.87
| Professional | | $1,353.87 | $1,353.87 | $1,353.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,703.68 / $11,160.65 / $11,160.65
| Facility | | $4,703.68 | $11,160.65 | $11,160.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.37 / $941.97 / $1,720.91
| Professional | | $728.37 | $941.97 | $1,720.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.35 / $982.47 / $1,720.91
| Professional | | $765.35 | $982.47 | $1,720.91 |