- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.85 / $4,144.67 / $4,144.67
| Professional | | $1,257.85 | $4,144.67 | $4,144.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.25 / $1,113.25 / $1,113.25
| Professional | | $1,113.25 | $1,113.25 | $1,113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.14 / $856.71 / $856.71
| Professional | | $517.14 | $856.71 | $856.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.00 / $1,139.97 / $1,370.74
| Facility | | $347.00 | $1,139.97 | $1,370.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.71 / $1,229.08 / $1,683.41
| Professional | | $856.71 | $1,229.08 | $1,683.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.80 / $537.49 / $716.66
| Professional | | $485.80 | $537.49 | $716.66 |