- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $641.78 / $641.78 / $641.78
| Facility | | $641.78 | $641.78 | $641.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.39 / $641.78 / $829.24
| Professional | | $321.39 | $641.78 | $829.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.59 / $1,123.80 / $1,199.53
| Facility | | $1,042.59 | $1,123.80 | $1,199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.21 / $1,044.01 / $1,123.80
| Professional | | $835.21 | $1,044.01 | $1,123.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.00 / $134.00 / $2,686.82
| Facility | | $134.00 | $134.00 | $2,686.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.25 / $1,253.66 / $1,576.39
| Professional | | $1,241.25 | $1,253.66 | $1,576.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.60 / $1,900.60 / $2,115.61
| Facility | | $1,900.60 | $1,900.60 | $2,115.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.25 / $1,241.25 / $1,241.25
| Professional | | $1,241.25 | $1,241.25 | $1,241.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $312.02 / $5,113.54
| Facility | | $100.00 | $312.02 | $5,113.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.75 / $510.55 / $1,042.23
| Professional | | $319.75 | $510.55 | $1,042.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.75 / $535.58 / $1,498.52
| Professional | | $319.75 | $535.58 | $1,498.52 |