- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.62 / $884.90 / $3,281.02
| Professional | | $668.62 | $884.90 | $3,281.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.38 / $1,006.38 / $1,006.38
| Professional | | $1,006.38 | $1,006.38 | $1,006.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.38 / $1,006.38 / $1,006.38
| Facility | | $1,006.38 | $1,006.38 | $1,006.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.87 / $1,006.38 / $1,045.84
| Professional | | $519.87 | $1,006.38 | $1,045.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $499.25 / $686.47 / $1,006.38
| Facility | | $499.25 | $686.47 | $1,006.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.62 / $1,006.38 / $1,308.30
| Professional | | $604.62 | $1,006.38 | $1,308.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.41 / $1,027.72 / $1,174.14
| Professional | | $847.41 | $1,027.72 | $1,174.14 |