- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.63 / $847.63 / $847.63
| Facility | | $847.63 | $847.63 | $847.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.63 / $867.86 / $1,514.14
| Professional | | $847.63 | $867.86 | $1,514.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.30 / $2,886.86 / $9,310.49
| Facility | | $915.30 | $2,886.86 | $9,310.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.30 / $1,491.41 / $1,894.52
| Professional | | $915.30 | $1,491.41 | $1,894.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.09 / $2,505.12 / $3,226.12
| Facility | | $2,059.09 | $2,505.12 | $3,226.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.33 / $1,721.31 / $1,721.31
| Professional | | $1,270.33 | $1,721.31 | $1,721.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.13 / $1,254.96 / $1,360.04
| Facility | | $1,122.13 | $1,254.96 | $1,360.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.12 / $1,254.96 / $2,248.88
| Professional | | $916.12 | $1,254.96 | $2,248.88 |
- 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
- $1,570.72 / $1,570.72 / $1,649.26
| Professional | | $1,570.72 | $1,570.72 | $1,649.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.53 / $1,232.53 / $1,232.53
| Professional | | $1,232.53 | $1,232.53 | $1,232.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,938.18 / $9,310.49 / $9,310.49
| Facility | | $3,938.18 | $9,310.49 | $9,310.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.86 / $1,037.00 / $1,894.52
| Professional | | $801.86 | $1,037.00 | $1,894.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $969.63 / $969.63 / $969.63
| Facility | | $969.63 | $969.63 | $969.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.56 / $1,037.00 / $1,894.52
| Professional | | $842.56 | $1,037.00 | $1,894.52 |