- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $776.25
| Professional | | $549.54 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,288.25
| Facility | | $1,071.52 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,071.52
| Professional | | $870.96 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $691.83 / $2,754.23
| Facility | | $630.96 | $691.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,137.96
| Facility | | $1,905.46 | $1,905.46 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $309.03 / $5,011.87
| Facility | | $100.00 | $309.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $467.74 / $954.99
| Professional | | $316.23 | $467.74 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.59 / $309.03 / $630.96
| Facility | | $7.59 | $309.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $676.08 / $1,348.96
| Professional | | $316.23 | $676.08 | $1,348.96 |