- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.83 / $1,240.50 / $4,802.06
| Professional | | $733.83 | $1,240.50 | $4,802.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.85 / $1,107.85 / $1,364.45
| Professional | | $1,107.85 | $1,107.85 | $1,364.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.85 / $1,107.85 / $1,107.85
| Facility | | $1,107.85 | $1,107.85 | $1,107.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.37 / $1,159.78 / $1,656.60
| Professional | | $684.37 | $1,159.78 | $1,656.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $558.17 / $863.66 / $1,390.73
| Facility | | $558.17 | $863.66 | $1,390.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.84 / $1,228.01 / $1,765.50
| Professional | | $804.84 | $1,228.01 | $1,765.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.24 / $1,527.51 / $1,796.12
| Professional | | $1,262.24 | $1,527.51 | $1,796.12 |