- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.98 / $3,441.98 / $3,441.98
| Professional | | $3,441.98 | $3,441.98 | $3,441.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.58 / $1,302.84 / $1,539.33
| Professional | | $1,198.58 | $1,302.84 | $1,539.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.36 / $1,250.86 / $1,763.75
| Professional | | $843.36 | $1,250.86 | $1,763.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $610.54 / $836.67 / $1,831.65
| Facility | | $610.54 | $836.67 | $1,831.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.97 / $1,189.22 / $1,561.96
| Professional | | $662.97 | $1,189.22 | $1,561.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.26 / $1,266.64 / $1,561.96
| Professional | | $708.26 | $1,266.64 | $1,561.96 |