- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.91 / $1,004.91 / $4,899.82
| Professional | | $1,004.91 | $1,004.91 | $4,899.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.38 / $461.22 / $1,369.97
| Professional | | $356.38 | $461.22 | $1,369.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.05 / $881.19 / $1,842.87
| Professional | | $307.05 | $881.19 | $1,842.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.55 / $751.85 / $1,278.15
| Facility | | $180.55 | $751.85 | $1,278.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.97 / $1,616.52 / $1,968.94
| Professional | | $881.97 | $1,616.52 | $1,968.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.97 / $1,595.15 / $1,968.94
| Professional | | $946.97 | $1,595.15 | $1,968.94 |