- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.05 / $2,442.05 / $2,442.05
| Professional | | $2,442.05 | $2,442.05 | $2,442.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.04 / $248.04 / $248.04
| Professional | | $248.04 | $248.04 | $248.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,666.86
| Facility | | $1,460.50 | $1,460.50 | $2,666.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,908.73 / $2,666.86
| Professional | | $1,460.50 | $1,908.73 | $2,666.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.16 / $2,080.80 / $3,053.97
| Facility | | $1,257.16 | $2,080.80 | $3,053.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,908.73 / $2,666.86
| Professional | | $1,460.50 | $1,908.73 | $2,666.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.01 / $1,095.38 / $1,825.63
| Professional | | $990.01 | $1,095.38 | $1,825.63 |