- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.29 / $1,019.74 / $3,737.34
| Professional | | $728.29 | $1,019.74 | $3,737.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.08 / $1,092.08 / $1,092.08
| Professional | | $1,092.08 | $1,092.08 | $1,092.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.08 / $1,092.08 / $1,092.08
| Facility | | $1,092.08 | $1,092.08 | $1,092.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.66 / $1,092.08 / $1,319.98
| Professional | | $575.66 | $1,092.08 | $1,319.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.42 / $744.47 / $1,092.08
| Facility | | $541.42 | $744.47 | $1,092.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.59 / $1,092.08 / $1,495.20
| Professional | | $671.59 | $1,092.08 | $1,495.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.17 / $1,155.34 / $1,274.86
| Professional | | $1,003.17 | $1,155.34 | $1,274.86 |