- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.87 / $601.87 / $601.87
| Facility | | $601.87 | $601.87 | $601.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.62 / $601.87 / $1,061.46
| Professional | | $450.62 | $601.87 | $1,061.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.09 / $1,112.48 / $7,369.29
| Facility | | $921.09 | $1,112.48 | $7,369.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.14 / $967.14 / $1,059.50
| Professional | | $522.14 | $967.14 | $1,059.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.78 / $152.78 / $157.22
| Facility | | $152.78 | $152.78 | $157.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.19 / $1,188.64 / $1,188.64
| Professional | | $975.19 | $1,188.64 | $1,188.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.40 / $833.40 / $1,317.74
| Facility | | $833.40 | $833.40 | $1,317.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.30 / $833.40 / $1,964.06
| Professional | | $116.30 | $833.40 | $1,964.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.61 / $1,082.61 / $1,082.61
| Professional | | $1,082.61 | $1,082.61 | $1,082.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.09 / $921.09 / $1,156.03
| Professional | | $921.09 | $921.09 | $1,156.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,369.29 / $7,369.29
| Facility | | $100.00 | $7,369.29 | $7,369.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.91 / $674.82 / $1,146.80
| Professional | | $509.91 | $674.82 | $1,146.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.91 / $678.78 / $1,366.20
| Professional | | $509.91 | $678.78 | $1,366.20 |