- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $724.44 / $2,187.76
| Professional | | $512.86 | $724.44 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,479.11 / $1,659.59
| Facility | | $851.14 | $1,479.11 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,584.89
| Professional | | $645.65 | $891.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $3,801.89
| Facility | | $1,479.11 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $2,187.76
| Professional | | $1,000.00 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $1,288.25
| Professional | | $537.03 | $812.83 | $1,288.25 |