- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $613.14 / $613.14 / $613.14
| Facility | | $613.14 | $613.14 | $613.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.97 / $613.14 / $1,105.92
| Professional | | $589.97 | $613.14 | $1,105.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $932.22 / $1,151.43 / $7,677.52
| Facility | | $932.22 | $1,151.43 | $7,677.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.95 / $978.83 / $1,096.59
| Professional | | $531.95 | $978.83 | $1,096.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.76 / $160.76 / $165.45
| Facility | | $160.76 | $160.76 | $165.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.76 / $1,250.83 / $1,250.83
| Professional | | $1,027.76 | $1,250.83 | $1,250.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,369.09
| Facility | | $606.51 | $606.51 | $1,369.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.23 / $606.51 / $2,034.38
| Professional | | $122.23 | $606.51 | $2,034.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.30 / $1,139.30 / $1,139.30
| Professional | | $1,139.30 | $1,139.30 | $1,139.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.22 / $932.22 / $932.22
| Professional | | $932.22 | $932.22 | $932.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,677.52 / $7,677.52
| Facility | | $100.00 | $7,677.52 | $7,677.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.48 / $698.58 / $1,185.50
| Professional | | $519.48 | $698.58 | $1,185.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.00 / $757.43 / $1,403.30
| Professional | | $520.00 | $757.43 | $1,403.30 |