- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.96 / $501.96 / $501.96
| Facility | | $501.96 | $501.96 | $501.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.18 / $1,162.94 / $2,249.50
| Facility | | $884.18 | $1,162.94 | $2,249.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.24 / $1,128.90 / $1,164.40
| Professional | | $1,025.24 | $1,128.90 | $1,164.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.93 / $1,289.93 / $1,612.42
| Professional | | $1,289.93 | $1,289.93 | $1,612.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.60 / $468.60 / $3,372.50
| Facility | | $255.60 | $468.60 | $3,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.00 / $426.00 / $2,051.90
| Professional | | $426.00 | $426.00 | $2,051.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $852.00 / $1,298.41 / $1,556.02
| Facility | | $852.00 | $1,298.41 | $1,556.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.00 / $1,397.23 / $1,817.60
| Professional | | $852.00 | $1,397.23 | $1,817.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.70 / $830.70 / $1,448.40
| Professional | | $830.70 | $830.70 | $1,448.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.70 / $426.00 / $1,384.50
| Professional | | $404.70 | $426.00 | $1,384.50 |