- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $523.87
| Professional | | $523.87 | $523.87 | $523.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.30 / $1,492.30 / $1,492.30
| Facility | | $1,492.30 | $1,492.30 | $1,492.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.34 / $1,359.78 / $1,699.73
| Professional | | $1,075.34 | $1,359.78 | $1,699.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.33 / $847.40 / $1,373.89
| Facility | | $706.33 | $847.40 | $1,373.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.68 / $449.03 / $1,472.78
| Professional | | $381.68 | $449.03 | $1,472.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.75 / $1,368.62 / $1,640.16
| Facility | | $965.75 | $1,368.62 | $1,640.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.07 / $1,368.62 / $1,640.16
| Professional | | $898.07 | $1,368.62 | $1,640.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.20 / $1,803.10 / $2,055.98
| Professional | | $1,070.20 | $1,803.10 | $2,055.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $381.68 / $748.39
| Professional | | $314.32 | $381.68 | $748.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.39 / $748.39 / $748.39
| Professional | | $748.39 | $748.39 | $748.39 |