- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,479.11
| Professional | | $977.24 | $977.24 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,148.15
| Professional | | $812.83 | $812.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $1,047.13 / $1,047.13
| Professional | | $120.23 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $645.65 / $1,513.56
| Professional | | $478.63 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $1,023.29
| Professional | | $977.24 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $501.19 / $1,122.02
| Facility | | $57.54 | $501.19 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $1,513.56
| Professional | | $575.44 | $645.65 | $1,513.56 |