- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.55 / $1,441.24 / $1,441.24
| Professional | | $648.55 | $1,441.24 | $1,441.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.33 / $941.33 / $1,032.34
| Facility | | $941.33 | $941.33 | $1,032.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.17 / $941.33 / $969.57
| Professional | | $687.17 | $941.33 | $969.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.19 / $1,159.40 / $1,645.94
| Facility | | $485.19 | $1,159.40 | $1,645.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.35 / $1,563.64 / $1,645.94
| Professional | | $1,481.35 | $1,563.64 | $1,645.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,214.70 / $1,446.62
| Professional | | $30.00 | $1,214.70 | $1,446.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,441.24 / $1,607.36 / $2,411.04
| Facility | | $1,441.24 | $1,607.36 | $2,411.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.16 / $1,193.38 / $1,728.24
| Professional | | $1,152.16 | $1,193.38 | $1,728.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.88 / $751.55 / $1,158.13
| Professional | | $694.88 | $751.55 | $1,158.13 |