- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.10 / $750.10 / $750.10
| Facility | | $750.10 | $750.10 | $750.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.10 / $815.17 / $1,511.78
| Professional | | $750.10 | $815.17 | $1,511.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $849.20 / $2,678.38 / $10,872.75
| Facility | | $849.20 | $2,678.38 | $10,872.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.26 / $1,319.79 / $1,676.51
| Professional | | $838.26 | $1,319.79 | $1,676.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.15 / $2,216.85 / $2,854.88
| Facility | | $1,822.15 | $2,216.85 | $2,854.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.14 / $1,523.23 / $1,523.23
| Professional | | $1,124.14 | $1,523.23 | $1,523.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $993.01 / $1,261.79 / $1,473.53
| Facility | | $993.01 | $1,261.79 | $1,473.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.68 / $1,473.53 / $2,640.75
| Professional | | $1,075.68 | $1,473.53 | $2,640.75 |
- 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
- $1,389.97 / $1,389.97 / $1,459.47
| Professional | | $1,389.97 | $1,389.97 | $1,459.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.71 / $1,157.71 / $1,157.71
| Professional | | $1,157.71 | $1,157.71 | $1,157.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,624.06 / $10,872.75 / $10,872.75
| Facility | | $4,624.06 | $10,872.75 | $10,872.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.58 / $917.66 / $1,676.51
| Professional | | $709.58 | $917.66 | $1,676.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.60 / $957.13 / $1,676.51
| Professional | | $745.60 | $957.13 | $1,676.51 |