- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $3,548.13 / $7,079.46
| Facility | | $912.01 | $3,548.13 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $1,202.26
| Professional | | $776.25 | $912.01 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $977.24 / $5,248.07
| Facility | | $660.69 | $977.24 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $6,309.57
| Professional | | $1,513.56 | $1,862.09 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,174.90
| Professional | | $776.25 | $776.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $1,318.26
| Facility | | $501.19 | $776.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $1,318.26
| Professional | | $457.09 | $549.54 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,318.26
| Professional | | $776.25 | $776.25 | $1,318.26 |