- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $605.04 / $605.04 / $605.04
| Facility | | $605.04 | $605.04 | $605.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.16 / $605.04 / $822.87
| Professional | | $596.16 | $605.04 | $822.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.10 / $1,085.60 / $5,719.94
| Facility | | $797.10 | $1,085.60 | $5,719.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.79 / $1,065.22 / $1,253.20
| Professional | | $558.79 | $1,065.22 | $1,253.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.49 / $1,455.49 / $1,497.93
| Facility | | $1,455.49 | $1,455.49 | $1,497.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.83 / $1,132.44 / $1,132.44
| Professional | | $936.83 | $1,132.44 | $1,132.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.66 / $542.66 / $1,091.71
| Facility | | $542.66 | $542.66 | $1,091.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.26 / $542.66 / $1,327.88
| Professional | | $461.26 | $542.66 | $1,327.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.48 / $1,031.48 / $1,031.48
| Professional | | $1,031.48 | $1,031.48 | $1,031.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.61 / $848.61 / $848.61
| Professional | | $848.61 | $848.61 | $848.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,719.94 / $5,719.94
| Facility | | $100.00 | $5,719.94 | $5,719.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.45 / $662.52 / $993.62
| Professional | | $452.45 | $662.52 | $993.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.45 / $662.52 / $1,253.20
| Professional | | $452.45 | $662.52 | $1,253.20 |