- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,751.60 / $2,751.60 / $5,188.14
| Facility | | $2,751.60 | $2,751.60 | $5,188.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.70 / $813.36 / $1,361.16
| Professional | | $553.70 | $813.36 | $1,361.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.77 / $902.86 / $1,356.73
| Professional | | $743.77 | $902.86 | $1,356.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.19 / $1,143.49 / $1,686.30
| Professional | | $662.19 | $1,143.49 | $1,686.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.67 / $1,060.79 / $1,768.27
| Professional | | $860.67 | $1,060.79 | $1,768.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,751.60 / $2,751.60 / $5,188.14
| Facility | | $2,751.60 | $2,751.60 | $5,188.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.70 / $813.36 / $1,361.16
| Professional | | $553.70 | $813.36 | $1,361.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.52 / $1,174.30 / $1,701.01
| Professional | | $883.52 | $1,174.30 | $1,701.01 |