- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.15 / $1,261.15 / $1,261.15
| Professional | | $1,261.15 | $1,261.15 | $1,261.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,317.41 / $1,317.41
| Professional | | $1,143.60 | $1,317.41 | $1,317.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $396.70
| Professional | | $148.88 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.81 / $752.81 / $1,261.15
| Professional | | $752.81 | $752.81 | $1,261.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.90 / $886.34 / $1,885.87
| Professional | | $590.90 | $886.34 | $1,885.87 |