- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.52 / $1,124.48 / $1,124.48
| Professional | | $801.52 | $1,124.48 | $1,124.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $902.06 / $902.06 / $902.06
| Facility | | $902.06 | $902.06 | $902.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.08 / $902.06 / $2,348.44
| Professional | | $139.08 | $902.06 | $2,348.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.91 / $1,124.48 / $1,414.17
| Facility | | $540.91 | $1,124.48 | $1,414.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.00 / $1,212.00 / $1,212.00
| Professional | | $1,212.00 | $1,212.00 | $1,212.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.02 / $547.76 / $1,054.72
| Facility | | $68.02 | $547.76 | $1,054.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.91 / $816.18 / $1,346.83
| Professional | | $540.91 | $816.18 | $1,346.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.77 / $8,818.61 / $8,818.61
| Facility | | $1,485.77 | $8,818.61 | $8,818.61 |