- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.51 / $1,777.51 / $8,228.79
| Professional | | $1,777.51 | $1,777.51 | $8,228.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.41 / $799.04 / $2,340.79
| Professional | | $617.41 | $799.04 | $2,340.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.77 / $1,510.68 / $3,159.35
| Professional | | $431.77 | $1,510.68 | $3,159.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.77 / $1,264.05 / $2,148.89
| Facility | | $317.77 | $1,264.05 | $2,148.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.91 / $2,697.89 / $3,310.72
| Professional | | $1,437.91 | $2,697.89 | $3,310.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.87 / $2,679.87 / $3,310.72
| Professional | | $571.87 | $2,679.87 | $3,310.72 |