- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $5,495.41
| Professional | | $1,862.09 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $2,884.03
| Professional | | $1,380.38 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $524.81 / $1,047.13
| Professional | | $281.84 | $524.81 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,981.07
| Professional | | $1,862.09 | $1,862.09 | $3,981.07 |