- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.48 / $985.38 / $1,355.33
| Professional | | $787.48 | $985.38 | $1,355.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.49 / $1,563.49 / $1,563.49
| Professional | | $1,563.49 | $1,563.49 | $1,563.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,459.20
| Facility | | $1,122.47 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.57 / $1,122.47 / $1,459.20
| Professional | | $341.57 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,459.20
| Facility | | $1,122.47 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.57 / $1,122.47 / $1,459.20
| Professional | | $341.57 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.54 / $1,232.19 / $1,483.87
| Professional | | $593.54 | $1,232.19 | $1,483.87 |