- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,174.90
| Professional | | $501.19 | $794.33 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,380.38 / $1,380.38
| Facility | | $724.44 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,122.02 / $1,380.38
| Professional | | $524.81 | $1,122.02 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,511.89
| Facility | | $1,000.00 | $1,288.25 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,511.89
| Professional | | $1,000.00 | $1,288.25 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $1,513.56
| Facility | | $724.44 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,023.29 / $1,380.38
| Professional | | $79.43 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $758.58
| Facility | | $575.44 | $724.44 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $575.44 / $660.69
| Professional | | $524.81 | $575.44 | $660.69 |