- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.08 / $1,041.42 / $1,603.26
| Professional | | $240.08 | $1,041.42 | $1,603.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.43 / $314.43 / $314.43
| Facility | | $314.43 | $314.43 | $314.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.65 / $314.43 / $483.74
| Professional | | $197.65 | $314.43 | $483.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.59 / $256.14 / $432.72
| Facility | | $91.59 | $256.14 | $432.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.89 / $320.36 / $492.83
| Professional | | $201.89 | $320.36 | $492.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.00 / $1,450.00 / $1,450.00
| Facility | | $1,450.00 | $1,450.00 | $1,450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.83 / $496.77 / $564.13
| Professional | | $437.83 | $496.77 | $564.13 |