- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.03 / $1,121.25 / $1,408.25
| Professional | | $981.03 | $1,121.25 | $1,408.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.94 / $328.94 / $328.94
| Facility | | $328.94 | $328.94 | $328.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $144.47 / $144.47
| Professional | | $144.47 | $144.47 | $144.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.00 / $504.00 / $1,767.72
| Facility | | $504.00 | $504.00 | $1,767.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $504.00 / $504.00
| Professional | | $141.11 | $504.00 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.00 / $1,095.14 / $2,242.50
| Professional | | $598.00 | $1,095.14 | $2,242.50 |