- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.07 / $981.96 / $1,302.45
| Professional | | $29.07 | $981.96 | $1,302.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,057.92 / $4,427.05 / $7,860.92
| Facility | | $2,057.92 | $4,427.05 | $7,860.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.72 / $764.38 / $1,321.46
| Professional | | $32.72 | $764.38 | $1,321.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.61 / $46.61 / $46.61
| Facility | | $46.61 | $46.61 | $46.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,077.57
| Professional | | $1,077.57 | $1,077.57 | $1,077.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,386.05
| Professional | | $32.34 | $32.34 | $1,386.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.22 / $1,066.19 / $1,361.67
| Facility | | $33.22 | $1,066.19 | $1,361.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.27 / $1,077.57 / $2,848.07
| Professional | | $70.27 | $1,077.57 | $2,848.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.67 / $1,599.53 / $2,183.96
| Professional | | $1,211.67 | $1,599.53 | $2,183.96 |