- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,348.96
| Professional | | $724.44 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,445.44
| Facility | | $1,122.02 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,995.26
| Professional | | $954.99 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $602.56 / $1,288.25
| Facility | | $77.62 | $602.56 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $851.14 / $1,318.26
| Professional | | $549.54 | $851.14 | $1,318.26 |