- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.44 / $2,354.80 / $2,354.80
| Professional | | $1,924.44 | $2,354.80 | $2,354.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.87 / $503.87 / $503.87
| Professional | | $503.87 | $503.87 | $503.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $192.51 / $7,745.52
| Professional | | $192.51 | $192.51 | $7,745.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.40 / $548.64 / $2,449.92
| Facility | | $243.40 | $548.64 | $2,449.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $210.50 / $7,745.52
| Professional | | $192.51 | $210.50 | $7,745.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.19 / $163.19 / $713.28
| Professional | | $163.19 | $163.19 | $713.28 |