- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.87 / $1,689.87 / $1,689.87
| Professional | | $1,689.87 | $1,689.87 | $1,689.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $192.51 / $5,835.72
| Professional | | $192.51 | $192.51 | $5,835.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.40 / $366.75 / $2,062.98
| Facility | | $243.40 | $366.75 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $192.51 / $5,835.72
| Professional | | $192.51 | $192.51 | $5,835.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.24 / $143.24 / $713.28
| Professional | | $143.24 | $143.24 | $713.28 |