- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.52 / $1,410.38 / $1,410.38
| Professional | | $1,066.52 | $1,410.38 | $1,410.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $1,519.02
| Facility | | $642.26 | $642.26 | $1,519.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $1,772.55 / $2,193.75
| Professional | | $1,755.00 | $1,772.55 | $2,193.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.60 / $2,922.26 / $8,276.54
| Facility | | $1,281.60 | $2,922.26 | $8,276.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.00 / $1,260.40 / $1,474.37
| Professional | | $644.00 | $1,260.40 | $1,474.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.80 / $172.10 / $172.10
| Facility | | $170.80 | $172.10 | $172.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.80 / $324.62 / $1,780.11
| Professional | | $170.80 | $324.62 | $1,780.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.44 / $921.48 / $1,437.19
| Professional | | $587.44 | $921.48 | $1,437.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.05 / $1,408.05 / $1,408.05
| Professional | | $1,408.05 | $1,408.05 | $1,408.05 |