- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.96 / $1,077.96 / $1,077.96
| Professional | | $1,077.96 | $1,077.96 | $1,077.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.51 / $204.51 / $204.51
| Professional | | $204.51 | $204.51 | $204.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,122.47
| Facility | | $1,122.47 | $1,122.47 | $1,122.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.82 / $1,122.47 / $2,398.56
| Professional | | $140.82 | $1,122.47 | $2,398.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.91 / $795.49 / $1,743.46
| Facility | | $135.91 | $795.49 | $1,743.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.82 / $1,122.47 / $2,398.56
| Professional | | $140.82 | $1,122.47 | $2,398.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.51 / $883.25 / $1,472.09
| Professional | | $809.51 | $883.25 | $1,472.09 |