- 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
- $616.60 / $794.33 / $1,445.44
| Professional | | $616.60 | $794.33 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $7,413.10
| Facility | | $1,258.93 | $1,445.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $1,445.44
| Professional | | $660.69 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,454.71
| Facility | | $1,513.56 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,258.93
| Professional | | $912.01 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,096.48
| Facility | | $812.83 | $1,023.29 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,096.48
| Professional | | $812.83 | $812.83 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,862.09
| Professional | | $1,230.27 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $7,413.10
| Facility | | $1,258.93 | $1,445.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,698.24
| Professional | | $676.08 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.10 / $1,047.13 / $1,862.09
| Facility | | $1.10 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $977.24 / $1,230.27
| Professional | | $616.60 | $977.24 | $1,230.27 |