- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.86 / $4,338.47 / $4,338.47
| Professional | | $744.86 | $4,338.47 | $4,338.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.45 / $1,364.45 / $1,364.45
| Professional | | $1,364.45 | $1,364.45 | $1,364.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,364.45 / $1,364.45 / $1,364.45
| Facility | | $1,364.45 | $1,364.45 | $1,364.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.91 / $1,364.45 / $1,407.86
| Professional | | $927.91 | $1,364.45 | $1,407.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.38 / $1,456.00 / $1,548.36
| Facility | | $667.38 | $1,456.00 | $1,548.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.60 / $1,237.03 / $1,784.30
| Professional | | $824.60 | $1,237.03 | $1,784.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.02 / $1,454.94 / $2,385.57
| Professional | | $1,159.02 | $1,454.94 | $2,385.57 |