- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.79 / $1,035.56 / $3,867.22
| Professional | | $787.79 | $1,035.56 | $3,867.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.47 / $1,181.47 / $1,181.47
| Professional | | $1,181.47 | $1,181.47 | $1,181.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.47 / $1,181.47 / $1,181.47
| Facility | | $1,181.47 | $1,181.47 | $1,181.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.37 / $1,181.47 / $1,212.31
| Professional | | $607.37 | $1,181.47 | $1,212.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $605.37 / $805.73 / $1,181.47
| Facility | | $605.37 | $805.73 | $1,181.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.05 / $1,181.47 / $1,538.60
| Professional | | $711.05 | $1,181.47 | $1,538.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.86 / $1,198.15 / $1,363.20
| Professional | | $961.86 | $1,198.15 | $1,363.20 |