- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,388.44 / $5,623.41
| Facility | | $891.25 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $2,884.03
| Professional | | $776.25 | $912.01 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $2,137.96 / $7,244.36
| Facility | | $56.23 | $2,137.96 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $6,025.60
| Professional | | $707.95 | $1,258.93 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $2,754.23
| Professional | | $954.99 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,479.11 / $8,511.38
| Facility | | $302.00 | $1,479.11 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,737.80
| Professional | | $1,000.00 | $1,258.93 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,311.31 / $5,888.44
| Facility | | $1,000.00 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $2,344.23
| Professional | | $912.01 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $2,137.96 / $7,244.36
| Facility | | $56.23 | $2,137.96 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $6,025.60
| Professional | | $707.95 | $1,258.93 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,884.03 / $4,677.35
| Facility | | $954.99 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,691.53
| Professional | | $912.01 | $1,348.96 | $2,691.53 |