- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $741.31 / $1,071.52
| Professional | | $489.78 | $741.31 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,148.15 / $5,011.87
| Professional | | $389.05 | $1,148.15 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,090.30 / $4,168.69
| Facility | | $2,691.53 | $3,090.30 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $138.04 / $8,511.38
| Facility | | $85.11 | $138.04 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,137.96
| Professional | | $1,230.27 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $1,096.48 / $2,691.53
| Professional | | $102.33 | $1,096.48 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,174.90 / $5,011.87
| Professional | | $389.05 | $1,174.90 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $4,466.84 / $7,762.47
| Facility | | $812.83 | $4,466.84 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,096.48 / $2,454.71
| Professional | | $181.97 | $1,096.48 | $2,454.71 |