- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.28 / $2,659.98 / $4,649.79
| Facility | | $960.28 | $2,659.98 | $4,649.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.12 / $960.28 / $1,200.34
| Professional | | $758.12 | $960.28 | $1,200.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,617.32 / $3,638.97 / $6,097.04
| Facility | | $1,617.32 | $3,638.97 | $6,097.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $1,263.53
| Professional | | $530.67 | $530.67 | $1,263.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.74 / $845.93 / $3,860.06
| Facility | | $722.74 | $845.93 | $3,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.51 / $1,547.51 / $1,832.12
| Professional | | $1,547.51 | $1,547.51 | $1,832.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.28 / $1,263.53 / $1,768.94
| Facility | | $960.28 | $1,263.53 | $1,768.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.82 / $1,768.94 / $2,527.06
| Professional | | $1,010.82 | $1,768.94 | $2,527.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $758.12
| Professional | | $530.67 | $530.67 | $758.12 |