- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Facility | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $479.81
| Professional | | $461.36 | $461.36 | $479.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.80 / $1,417.80 / $2,300.41
| Facility | | $1,417.80 | $1,417.80 | $2,300.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $3,092.01
| Professional | | $461.36 | $461.36 | $3,092.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Facility | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $693.19 / $8,090.00
| Facility | | $461.36 | $693.19 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.93 / $723.93 / $851.68
| Professional | | $723.93 | $723.93 | $851.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.80 / $1,417.80 / $2,300.41
| Facility | | $1,417.80 | $1,417.80 | $2,300.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $3,092.01
| Professional | | $461.36 | $461.36 | $3,092.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $953.54
| Professional | | $461.36 | $461.36 | $953.54 |