- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.33 / $1,265.33 / $1,265.33
| Professional | | $1,265.33 | $1,265.33 | $1,265.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.15 / $199.15 / $225.70
| Professional | | $199.15 | $199.15 | $225.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,617.45 / $1,617.45 / $1,617.45
| Facility | | $1,617.45 | $1,617.45 | $1,617.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.05 / $2,086.00 / $2,938.00
| Professional | | $1,223.05 | $2,086.00 | $2,938.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.48 / $1,108.48 / $1,108.48
| Facility | | $1,108.48 | $1,108.48 | $1,108.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.58 / $1,962.90 / $2,356.94
| Professional | | $701.58 | $1,962.90 | $2,356.94 |