- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.11 / $785.11 / $3,852.43
| Professional | | $737.11 | $785.11 | $3,852.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.27 / $1,177.27 / $1,177.27
| Professional | | $1,177.27 | $1,177.27 | $1,177.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.27 / $1,177.27 / $1,177.27
| Facility | | $1,177.27 | $1,177.27 | $1,177.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.22 / $1,177.27 / $1,234.42
| Professional | | $612.22 | $1,177.27 | $1,234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.38 / $802.15 / $1,177.27
| Facility | | $583.38 | $802.15 | $1,177.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.79 / $1,177.27 / $1,533.70
| Professional | | $708.79 | $1,177.27 | $1,533.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.34 / $1,217.92 / $1,387.97
| Professional | | $997.34 | $1,217.92 | $1,387.97 |