- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.57 / $1,320.30 / $1,650.38
| Professional | | $833.57 | $1,320.30 | $1,650.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.30 / $1,913.52 / $2,513.00
| Professional | | $251.30 | $1,913.52 | $2,513.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $3,787.50
| Professional | | $1,232.84 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.57 / $1,320.30 / $1,716.60
| Professional | | $833.57 | $1,320.30 | $1,716.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,450.41 / $3,787.50
| Professional | | $1,232.84 | $1,450.41 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.80 / $2,391.90 / $2,487.90
| Professional | | $1,796.80 | $2,391.90 | $2,487.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.78 / $1,150.96 / $1,977.07
| Professional | | $834.78 | $1,150.96 | $1,977.07 |