- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $891.25 / $1,288.25
| Facility | | $363.08 | $891.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $363.08 / $467.74
| Professional | | $309.03 | $363.08 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,122.02
| Professional | | $891.25 | $891.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $602.56 / $851.14
| Professional | | $151.36 | $602.56 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $562.34 / $1,071.52
| Facility | | $467.74 | $562.34 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $467.74 / $1,862.09
| Professional | | $281.84 | $467.74 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $501.19 / $1,000.00
| Professional | | $467.74 | $501.19 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $1,071.52
| Facility | | $467.74 | $467.74 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $1,174.90
| Professional | | $281.84 | $281.84 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |