- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $3,715.35
| Professional | | $1,737.80 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $588.84
| Professional | | $190.55 | $190.55 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $7,585.78
| Professional | | $588.84 | $794.33 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $3,019.95
| Professional | | $707.95 | $707.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $190.55 / $1,380.38
| Facility | | $138.04 | $190.55 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $776.25 / $1,023.29
| Professional | | $562.34 | $776.25 | $1,023.29 |