- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.15 / $1,641.85 / $1,641.85
| Professional | | $718.15 | $1,641.85 | $1,641.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,025.33 / $1,025.33 / $1,143.14
| Facility | | $1,025.33 | $1,025.33 | $1,143.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.49 / $1,025.33 / $1,093.05
| Professional | | $748.49 | $1,025.33 | $1,093.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.66 / $1,379.25 / $1,875.04
| Facility | | $516.66 | $1,379.25 | $1,875.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.54 / $1,781.29 / $1,875.04
| Professional | | $1,687.54 | $1,781.29 | $1,875.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,383.78 / $1,647.98
| Professional | | $30.00 | $1,383.78 | $1,647.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.85 / $1,831.09 / $2,746.64
| Facility | | $1,641.85 | $1,831.09 | $2,746.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.53 / $1,368.78 / $1,968.79
| Professional | | $1,312.53 | $1,368.78 | $1,968.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.96 / $800.32 / $1,252.85
| Professional | | $739.96 | $800.32 | $1,252.85 |