- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.60 / $477.60 / $477.60
| Professional | | $477.60 | $477.60 | $477.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.29 / $682.29 / $3,353.46
| Facility | | $682.29 | $682.29 | $3,353.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.30 / $77.30 / $123.53
| Professional | | $77.30 | $77.30 | $123.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.83 / $545.83 / $1,064.36
| Professional | | $545.83 | $545.83 | $1,064.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.49 / $1,274.91 / $3,495.78
| Facility | | $443.49 | $1,274.91 | $3,495.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.91 / $830.91 / $995.52
| Professional | | $830.91 | $830.91 | $995.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.29 / $818.75 / $1,009.79
| Professional | | $682.29 | $818.75 | $1,009.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.41 / $682.29 / $1,159.90
| Facility | | $542.41 | $682.29 | $1,159.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.00 / $1,350.93 / $1,637.50
| Professional | | $805.00 | $1,350.93 | $1,637.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.11 / $704.81 / $1,418.96
| Facility | | $354.11 | $704.81 | $1,418.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.11 / $784.63 / $1,498.99
| Professional | | $354.11 | $784.63 | $1,498.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $886.98
| Professional | | $286.56 | $409.37 | $886.98 |