- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $962.61 / $1,289.21
| Professional | | $645.61 | $962.61 | $1,289.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.41 / $1,852.41 / $1,852.41
| Professional | | $1,852.41 | $1,852.41 | $1,852.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,082.51
| Facility | | $173.31 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,114.99
| Professional | | $173.31 | $1,082.51 | $1,114.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,082.51
| Facility | | $173.31 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,114.99
| Professional | | $173.31 | $1,082.51 | $1,114.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.54 / $1,231.95 / $1,720.67
| Professional | | $647.54 | $1,231.95 | $1,720.67 |