- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.15 / $800.40 / $1,000.50
| Professional | | $536.15 | $800.40 | $1,000.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.26 / $1,334.72 / $1,512.60
| Professional | | $151.26 | $1,334.72 | $1,512.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $1,061.01
| Facility | | $642.26 | $642.26 | $1,061.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.91 / $642.26 / $2,193.75
| Professional | | $545.91 | $642.26 | $2,193.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.23 / $1,134.45 / $1,210.08
| Professional | | $1,011.23 | $1,134.45 | $1,210.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.15 / $807.73 / $1,067.20
| Professional | | $536.15 | $807.73 | $1,067.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $1,061.01
| Facility | | $642.26 | $642.26 | $1,061.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.91 / $642.26 / $2,193.75
| Professional | | $545.91 | $642.26 | $2,193.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.67 / $1,454.00 / $1,454.00
| Professional | | $1,155.67 | $1,454.00 | $1,454.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.75 / $844.47 / $1,564.50
| Professional | | $612.75 | $844.47 | $1,564.50 |