- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.06 / $1,061.28 / $2,872.80
| Facility | | $656.06 | $1,061.28 | $2,872.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.60 / $478.80 / $612.00
| Professional | | $292.60 | $478.80 | $612.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.20 / $1,884.44 / $2,985.21
| Facility | | $496.20 | $1,884.44 | $2,985.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.43 / $687.17 / $3,328.47
| Professional | | $472.43 | $687.17 | $3,328.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.19 / $1,123.20 / $2,012.40
| Facility | | $418.19 | $1,123.20 | $2,012.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.40 / $720.00 / $1,299.60
| Facility | | $482.40 | $720.00 | $1,299.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.39 / $302.39 / $3,600.00
| Professional | | $302.39 | $302.39 | $3,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.39 / $302.39 / $432.00
| Professional | | $302.39 | $302.39 | $432.00 |