- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.30 / $1,251.61 / $1,251.61
| Professional | | $1,122.30 | $1,251.61 | $1,251.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.01 / $1,997.01 / $1,997.01
| Professional | | $1,997.01 | $1,997.01 | $1,997.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,434.31 / $1,639.62
| Professional | | $188.66 | $1,434.31 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.39 / $1,170.58 / $1,408.75
| Professional | | $780.39 | $1,170.58 | $1,408.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.69 / $2,141.37 / $2,725.38
| Professional | | $1,932.69 | $2,141.37 | $2,725.38 |