- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $1,412.54 / $1,412.54
| Facility | | $120.23 | $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
- 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
- $1,348.96 / $1,348.96 / $2,089.30
| Facility | | $1,348.96 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,621.81
| Professional | | $1,412.54 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $537.03 / $2,238.72
| Facility | | $151.36 | $537.03 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $1,258.93 / $1,479.11
| Professional | | $158.49 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,479.11
| Facility | | $1,412.54 | $1,412.54 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $1,479.11
| Professional | | $1,412.54 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $50,118.72 / $75,857.76
| Facility | | $1,737.80 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $194.98 / $1,584.89
| Professional | | $125.89 | $194.98 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,584.89
| Facility | | $1,412.54 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $1,479.11
| Professional | | $1,412.54 | $1,479.11 | $1,479.11 |