- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.77 / $515.77 / $515.77
| Facility | | $515.77 | $515.77 | $515.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.77 / $568.51 / $756.08
| Professional | | $515.77 | $568.51 | $756.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.34 / $3,052.40 / $5,632.19
| Facility | | $921.34 | $3,052.40 | $5,632.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.43 / $876.93 / $1,152.80
| Professional | | $489.43 | $876.93 | $1,152.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.93 / $1,524.35 / $1,963.07
| Facility | | $1,288.93 | $1,524.35 | $1,963.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.98 / $772.98 / $798.29
| Professional | | $772.98 | $772.98 | $798.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.41 / $782.41 / $867.63
| Facility | | $782.41 | $782.41 | $867.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.16 / $782.41 / $1,402.13
| Professional | | $571.16 | $782.41 | $1,402.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.77 / $955.77 / $1,003.56
| Professional | | $955.77 | $955.77 | $1,003.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.14 / $882.14 / $882.14
| Professional | | $882.14 | $882.14 | $882.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.26 / $5,632.19 / $5,632.19
| Facility | | $2,455.26 | $5,632.19 | $5,632.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.20 / $588.91 / $1,152.80
| Professional | | $449.20 | $588.91 | $1,152.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.84 / $588.91 / $1,152.80
| Professional | | $456.84 | $588.91 | $1,152.80 |