- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.70 / $888.52 / $3,447.26
| Professional | | $685.70 | $888.52 | $3,447.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.86 / $1,097.86 / $1,097.86
| Professional | | $1,097.86 | $1,097.86 | $1,097.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.86 / $1,097.86 / $1,097.86
| Facility | | $1,097.86 | $1,097.86 | $1,097.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.98 / $1,097.86 / $1,159.33
| Professional | | $532.98 | $1,097.86 | $1,159.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.12 / $666.40 / $1,097.86
| Facility | | $533.12 | $666.40 | $1,097.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.50 / $1,089.18 / $1,432.06
| Professional | | $642.50 | $1,089.18 | $1,432.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.34 / $1,091.44 / $1,302.83
| Professional | | $912.34 | $1,091.44 | $1,302.83 |