- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.66 / $3,008.50 / $7,325.50
| Facility | | $769.66 | $3,008.50 | $7,325.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.35 / $576.77 / $942.61
| Professional | | $505.35 | $576.77 | $942.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.50 / $4,032.00 / $8,520.00
| Facility | | $2,420.50 | $4,032.00 | $8,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.83 / $712.40 / $1,148.80
| Professional | | $532.83 | $712.40 | $1,148.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.46 / $918.05 / $1,113.50
| Facility | | $658.46 | $918.05 | $1,113.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $797.90 / $1,252.24
| Professional | | $561.16 | $797.90 | $1,252.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.00 / $3,724.00 / $7,934.00
| Facility | | $1,747.00 | $3,724.00 | $7,934.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.73 / $735.68 / $1,286.00
| Professional | | $515.73 | $735.68 | $1,286.00 |