- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.48 / $1,336.09 / $3,049.09
| Facility | | $878.48 | $1,336.09 | $3,049.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.13 / $878.48 / $935.26
| Professional | | $708.13 | $878.48 | $935.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.67 / $1,960.71 / $3,306.82
| Facility | | $457.67 | $1,960.71 | $3,306.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.40 / $2,046.93 / $2,906.65
| Professional | | $681.40 | $2,046.93 | $2,906.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.46 / $4,297.37 / $7,667.90
| Facility | | $868.46 | $4,297.37 | $7,667.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.50 / $2,434.36 / $3,300.14
| Professional | | $1,536.50 | $2,434.36 | $3,300.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.60 / $801.65 / $2,344.69
| Professional | | $614.60 | $801.65 | $2,344.69 |