- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $776.25 / $10,000.00
| Facility | | $588.84 | $776.25 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $602.56 / $812.83
| Professional | | $588.84 | $602.56 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,000.00
| Facility | | $478.63 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,445.44 / $1,778.28
| Professional | | $181.97 | $1,445.44 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,445.44 / $1,445.44
| Facility | | $831.76 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $831.76
| Professional | | $645.65 | $645.65 | $831.76 |