- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.65 / $911.33 / $3,380.97
| Professional | | $688.65 | $911.33 | $3,380.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.34 / $1,036.34 / $1,036.34
| Professional | | $1,036.34 | $1,036.34 | $1,036.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.34 / $1,036.34 / $1,036.34
| Facility | | $1,036.34 | $1,036.34 | $1,036.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.63 / $1,036.34 / $1,077.28
| Professional | | $534.63 | $1,036.34 | $1,077.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.23 / $707.07 / $1,036.34
| Facility | | $514.23 | $707.07 | $1,036.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.74 / $1,036.34 / $1,347.50
| Professional | | $622.74 | $1,036.34 | $1,347.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.25 / $1,059.05 / $1,341.08
| Professional | | $873.25 | $1,059.05 | $1,341.08 |