- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.48 / $1,107.74 / $1,107.74
| Professional | | $498.48 | $1,107.74 | $1,107.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.52 / $723.52 / $723.52
| Facility | | $723.52 | $723.52 | $723.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.16 / $723.52 / $745.23
| Professional | | $528.16 | $723.52 | $745.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.06 / $906.65 / $1,265.07
| Facility | | $848.06 | $906.65 | $1,265.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.56 / $1,201.82 / $1,265.07
| Professional | | $1,138.56 | $1,201.82 | $1,265.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $945.10 / $1,138.56
| Professional | | $30.00 | $945.10 | $1,138.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.74 / $1,235.42 / $1,853.13
| Facility | | $1,107.74 | $1,235.42 | $1,853.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.55 / $917.27 / $1,328.32
| Professional | | $885.55 | $917.27 | $1,328.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.09 / $577.66 / $1,584.22
| Professional | | $534.09 | $577.66 | $1,584.22 |