- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.03 / $1,261.10 / $4,498.33
| Professional | | $945.03 | $1,261.10 | $4,498.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.73 / $1,400.73 / $1,400.73
| Professional | | $1,400.73 | $1,400.73 | $1,400.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.73 / $1,400.73 / $1,400.73
| Facility | | $1,400.73 | $1,400.73 | $1,400.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.84 / $1,382.25 / $1,400.73
| Professional | | $692.84 | $1,382.25 | $1,400.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.21 / $943.54 / $1,400.73
| Facility | | $686.21 | $943.54 | $1,400.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.86 / $1,382.25 / $1,860.60
| Professional | | $859.86 | $1,382.25 | $1,860.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.55 / $1,370.87 / $1,563.53
| Professional | | $1,150.55 | $1,370.87 | $1,563.53 |