- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.77 / $580.03 / $3,044.44
| Professional | | $415.77 | $580.03 | $3,044.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.33 / $1,067.33 / $1,067.33
| Professional | | $1,067.33 | $1,067.33 | $1,067.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.03 / $1,147.60 / $1,147.60
| Facility | | $702.03 | $1,147.60 | $1,147.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.03 / $933.23 / $1,147.60
| Professional | | $702.03 | $933.23 | $1,147.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $538.42 / $1,092.96 / $1,147.60
| Facility | | $538.42 | $1,092.96 | $1,147.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.03 / $861.33 / $1,148.44
| Professional | | $702.03 | $861.33 | $1,148.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.46 / $481.81 / $737.30
| Professional | | $435.46 | $481.81 | $737.30 |