- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.50 / $1,222.42 / $1,222.42
| Professional | | $1,007.50 | $1,222.42 | $1,222.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.53 / $1,602.52 / $1,602.52
| Professional | | $1,031.53 | $1,602.52 | $1,602.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.08 / $796.08 / $936.57
| Professional | | $796.08 | $796.08 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.50 / $1,155.50 / $1,222.42
| Professional | | $1,007.50 | $1,155.50 | $1,222.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.40 / $96.58 / $1,220.68
| Professional | | $53.40 | $96.58 | $1,220.68 |