- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.28 / $857.55 / $921.60
| Professional | | $737.28 | $857.55 | $921.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.21 / $112.26 / $1,078.27
| Facility | | $91.21 | $112.26 | $1,078.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.21 / $98.23 / $1,161.22
| Professional | | $91.21 | $98.23 | $1,161.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,560.25
| Facility | | $606.51 | $606.51 | $1,560.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $606.51 / $6,524.83
| Professional | | $112.05 | $606.51 | $6,524.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.00 / $804.93 / $1,165.27
| Professional | | $572.00 | $804.93 | $1,165.27 |