- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.58 / $622.58 / $622.58
| Facility | | $622.58 | $622.58 | $622.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.61 / $622.58 / $622.58
| Professional | | $516.61 | $622.58 | $622.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.45 / $1,203.10 / $1,503.89
| Professional | | $951.45 | $1,203.10 | $1,503.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.10 / $749.94 / $1,215.88
| Facility | | $625.10 | $749.94 | $1,215.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.78 / $397.39 / $3,298.35
| Professional | | $337.78 | $397.39 | $3,298.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.78 / $861.02 / $1,695.54
| Facility | | $794.78 | $861.02 | $1,695.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.78 / $794.78 / $1,364.38
| Professional | | $794.78 | $794.78 | $1,364.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.37 / $1,595.73 / $1,819.53
| Professional | | $1,356.37 | $1,595.73 | $1,819.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.17 / $337.78 / $662.32
| Professional | | $278.17 | $337.78 | $662.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.32 / $662.32 / $662.32
| Professional | | $662.32 | $662.32 | $662.32 |