- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.61 / $1,289.21 / $1,289.21
| Professional | | $962.61 | $1,289.21 | $1,289.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.41 / $1,852.41 / $1,852.41
| Professional | | $1,852.41 | $1,852.41 | $1,852.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $975.26
| Facility | | $975.26 | $975.26 | $975.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.97 / $975.26 / $1,004.52
| Professional | | $828.97 | $975.26 | $1,004.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $975.26
| Facility | | $975.26 | $975.26 | $975.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $1,004.52
| Professional | | $975.26 | $975.26 | $1,004.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.54 / $1,231.95 / $1,720.67
| Professional | | $647.54 | $1,231.95 | $1,720.67 |