- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.88 / $370.88 / $463.59
| Professional | | $370.88 | $370.88 | $463.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,528.40 / $16,528.40 / $16,528.40
| Facility | | $16,528.40 | $16,528.40 | $16,528.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.46 / $2,110.46 / $2,110.46
| Professional | | $2,110.46 | $2,110.46 | $2,110.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $685.70 / $863.16 / $1,303.27
| Facility | | $685.70 | $863.16 | $1,303.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.16 / $1,180.78 / $1,543.52
| Professional | | $863.16 | $1,180.78 | $1,543.52 |