- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.74 / $3,959.48 / $3,959.48
| Professional | | $540.74 | $3,959.48 | $3,959.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.14 / $1,388.14 / $1,388.14
| Professional | | $1,388.14 | $1,388.14 | $1,388.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.46 / $1,492.53 / $1,492.53
| Facility | | $907.46 | $1,492.53 | $1,492.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.46 / $1,492.53 / $1,492.53
| Professional | | $907.46 | $1,492.53 | $1,492.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.27 / $1,421.46 / $1,492.53
| Facility | | $700.27 | $1,421.46 | $1,492.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.46 / $1,120.20 / $1,493.60
| Professional | | $907.46 | $1,120.20 | $1,493.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.35 / $626.62 / $717.31
| Professional | | $566.35 | $626.62 | $717.31 |