- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.95 / $1,001.95 / $1,001.95
| Professional | | $1,001.95 | $1,001.95 | $1,001.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.78 / $1,135.65 / $1,135.65
| Professional | | $1,018.78 | $1,135.65 | $1,135.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $881.10 / $881.10 / $1,167.58
| Facility | | $881.10 | $881.10 | $1,167.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.87 / $881.10 / $1,015.15
| Professional | | $109.87 | $881.10 | $1,015.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.32 / $1,001.95 / $1,001.95
| Professional | | $831.32 | $1,001.95 | $1,001.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.12 / $752.14 / $2,136.28
| Professional | | $552.12 | $752.14 | $2,136.28 |