- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.74 / $1,201.65 / $1,201.65
| Professional | | $540.74 | $1,201.65 | $1,201.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.73 / $907.46 / $907.46
| Facility | | $860.73 | $907.46 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.45 / $662.45 / $967.40
| Professional | | $662.45 | $662.45 | $967.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.54 / $966.66 / $1,372.31
| Facility | | $404.54 | $966.66 | $1,372.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.08 / $1,303.69 / $1,372.31
| Professional | | $1,235.08 | $1,303.69 | $1,372.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,025.22 / $1,235.08
| Professional | | $30.00 | $1,025.22 | $1,235.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.65 / $1,340.15 / $2,010.23
| Facility | | $1,201.65 | $1,340.15 | $2,010.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.62 / $995.02 / $1,440.93
| Professional | | $960.62 | $995.02 | $1,440.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.37 / $626.62 / $965.61
| Professional | | $579.37 | $626.62 | $965.61 |