- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.51 / $1,120.24 / $3,032.40
| Facility | | $692.51 | $1,120.24 | $3,032.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.40 / $570.00 / $646.00
| Professional | | $505.40 | $570.00 | $646.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.35 / $1,755.88 / $2,781.56
| Facility | | $462.35 | $1,755.88 | $2,781.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.20 / $640.29 / $3,101.40
| Professional | | $440.20 | $640.29 | $3,101.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.44 / $1,506.70 / $2,223.00
| Facility | | $1,116.44 | $1,506.70 | $2,223.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.20 / $760.00 / $1,371.81
| Facility | | $509.20 | $760.00 | $1,371.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $319.20 / $3,800.00
| Professional | | $319.20 | $319.20 | $3,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $319.20 / $456.00
| Professional | | $319.20 | $319.20 | $456.00 |