- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.01 / $337.01 / $337.01
| Facility | | $337.01 | $337.01 | $337.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.08 / $337.01 / $600.00
| Professional | | $303.08 | $337.01 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.26 / $1,176.44 / $1,470.55
| Professional | | $855.26 | $1,176.44 | $1,470.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.08 / $569.54 / $2,000.00
| Facility | | $303.08 | $569.54 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.73 / $507.77 / $16,280.00
| Professional | | $228.73 | $507.77 | $16,280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.48 / $880.18 / $1,134.60
| Facility | | $683.48 | $880.18 | $1,134.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.48 / $913.70 / $1,134.60
| Professional | | $683.48 | $913.70 | $1,134.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.35 / $514.66 / $637.61
| Professional | | $329.35 | $514.66 | $637.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,324.80 / $5,291.50 / $5,291.50
| Professional | | $4,324.80 | $5,291.50 | $5,291.50 |