- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.34 / $783.84 / $979.80
| Professional | | $533.34 | $783.84 | $979.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.18 / $1,491.80 / $1,491.80
| Professional | | $149.18 | $1,491.80 | $1,491.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,658.68 / $1,658.68 / $1,658.68
| Facility | | $1,658.68 | $1,658.68 | $1,658.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.25 / $1,223.23 / $2,160.94
| Professional | | $130.25 | $1,223.23 | $2,160.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.87 / $783.84 / $1,045.11
| Professional | | $494.87 | $783.84 | $1,045.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,658.68 / $1,658.68 / $1,658.68
| Facility | | $1,658.68 | $1,658.68 | $1,658.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $2,160.94
| Professional | | $124.05 | $1,223.23 | $2,160.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.00 / $1,420.00 / $1,670.60
| Professional | | $1,420.00 | $1,420.00 | $1,670.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.63 / $752.06 / $1,231.02
| Professional | | $506.63 | $752.06 | $1,231.02 |