- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.85 / $937.85 / $1,082.13
| Professional | | $937.85 | $937.85 | $1,082.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.86 / $1,554.86 / $1,554.86
| Professional | | $1,554.86 | $1,554.86 | $1,554.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.11 / $1,200.11 / $1,412.54
| Facility | | $1,200.11 | $1,200.11 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.09 / $1,141.05 / $1,407.32
| Professional | | $876.09 | $1,141.05 | $1,407.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.11 / $1,200.11 / $1,412.54
| Facility | | $1,200.11 | $1,200.11 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.09 / $1,200.11 / $1,407.32
| Professional | | $876.09 | $1,200.11 | $1,407.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.20 / $1,138.45 / $2,221.75
| Professional | | $639.20 | $1,138.45 | $2,221.75 |