- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.61 / $1,322.67 / $1,322.67
| Professional | | $599.61 | $1,322.67 | $1,322.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.15 / $713.15 / $954.44
| Facility | | $713.15 | $713.15 | $954.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.60 / $713.14 / $760.25
| Professional | | $520.60 | $713.14 | $760.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.58 / $1,064.03 / $1,510.52
| Facility | | $367.58 | $1,064.03 | $1,510.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.47 / $1,434.99 / $1,510.52
| Professional | | $1,359.47 | $1,434.99 | $1,510.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,128.47 / $1,359.47
| Professional | | $30.00 | $1,128.47 | $1,359.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.67 / $1,475.12 / $2,212.67
| Facility | | $1,322.67 | $1,475.12 | $2,212.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.35 / $1,057.35 / $1,586.05
| Professional | | $1,057.35 | $1,057.35 | $1,586.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.42 / $569.38 / $1,009.29
| Professional | | $526.42 | $569.38 | $1,009.29 |