- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.46 / $3,746.40 / $3,746.40
| Professional | | $825.46 | $3,746.40 | $3,746.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.55 / $1,152.55 / $1,383.06
| Professional | | $1,152.55 | $1,152.55 | $1,383.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.55 / $1,152.55 / $1,152.55
| Facility | | $1,152.55 | $1,152.55 | $1,152.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.77 / $1,152.55 / $1,223.35
| Professional | | $772.77 | $1,152.55 | $1,223.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.24 / $1,274.65 / $1,350.39
| Facility | | $568.24 | $1,274.65 | $1,350.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.64 / $1,054.07 / $1,520.40
| Professional | | $702.64 | $1,054.07 | $1,520.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.99 / $1,255.04 / $2,012.81
| Professional | | $986.99 | $1,255.04 | $2,012.81 |