- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.50 / $1,384.50 / $2,619.90
| Facility | | $816.50 | $1,384.50 | $2,619.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.80 / $525.40 / $603.50
| Professional | | $482.80 | $525.40 | $603.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.33 / $2,130.00 / $3,854.59
| Facility | | $335.33 | $2,130.00 | $3,854.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.02 / $335.33 / $476.16
| Professional | | $285.02 | $335.33 | $476.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.00 / $923.00 / $1,384.50
| Facility | | $710.00 | $923.00 | $1,384.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.00 / $852.00 / $1,065.00
| Professional | | $710.00 | $852.00 | $1,065.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.09 / $869.57 / $1,036.43
| Professional | | $816.09 | $869.57 | $1,036.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.20 / $426.00 / $780.29
| Professional | | $298.20 | $426.00 | $780.29 |