- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.45 / $5,304.62 / $5,304.62
| Professional | | $724.45 | $5,304.62 | $5,304.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.97 / $1,572.97 / $1,572.97
| Professional | | $1,572.97 | $1,572.97 | $1,572.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.48 / $1,691.26 / $1,691.26
| Facility | | $1,006.48 | $1,691.26 | $1,691.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.48 / $1,691.26 / $1,691.26
| Professional | | $1,006.48 | $1,691.26 | $1,691.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.02 / $1,610.72 / $1,691.26
| Facility | | $898.02 | $1,610.72 | $1,691.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.36 / $1,297.50 / $1,783.68
| Professional | | $1,269.36 | $1,297.50 | $1,783.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.28 / $803.57 / $1,229.68
| Professional | | $726.28 | $803.57 | $1,229.68 |