- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.64 / $1,219.05 / $1,419.98
| Professional | | $759.64 | $1,219.05 | $1,419.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $629.00 / $2,530.00
| Facility | | $582.00 | $629.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.10 / $1,109.10 / $1,109.10
| Professional | | $1,109.10 | $1,109.10 | $1,109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.08 / $1,495.26 / $2,095.91
| Professional | | $1,187.08 | $1,495.26 | $2,095.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.45 / $1,328.43 / $2,573.42
| Professional | | $968.45 | $1,328.43 | $2,573.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.26 / $1,640.55 / $1,822.83
| Professional | | $1,495.26 | $1,640.55 | $1,822.83 |