- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.45 / $3,907.05 / $3,907.05
| Professional | | $1,126.45 | $3,907.05 | $3,907.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.33 / $1,240.33 / $1,240.33
| Professional | | $1,240.33 | $1,240.33 | $1,240.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.38 / $1,333.62 / $1,333.62
| Facility | | $702.38 | $1,333.62 | $1,333.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.38 / $1,084.51 / $1,333.62
| Professional | | $702.38 | $1,084.51 | $1,333.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.69 / $1,270.10 / $1,333.62
| Facility | | $626.69 | $1,270.10 | $1,333.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.38 / $1,000.94 / $1,334.58
| Professional | | $702.38 | $1,000.94 | $1,334.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.84 / $560.78 / $889.39
| Professional | | $506.84 | $560.78 | $889.39 |