- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,584.89
| Professional | | $1,412.54 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $467.74 / $6,456.54
| Facility | | $125.89 | $467.74 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $3,090.30
| Professional | | $125.89 | $125.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $234.42 / $8,511.38
| Facility | | $134.90 | $234.42 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $199.53 / $295.12
| Professional | | $147.91 | $199.53 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $467.74 / $6,456.54
| Facility | | $125.89 | $467.74 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $3,090.30
| Professional | | $125.89 | $125.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $2,951.21
| Facility | | $1,380.38 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,412.54 / $1,479.11
| Professional | | $125.89 | $1,412.54 | $1,479.11 |