- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.06 / $1,690.76 / $6,834.70
| Professional | | $369.06 | $1,690.76 | $6,834.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.39 / $517.39 / $517.39
| Facility | | $517.39 | $517.39 | $517.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.98 / $517.39 / $1,780.88
| Professional | | $348.98 | $517.39 | $1,780.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.39 / $1,972.10 / $2,296.61
| Facility | | $517.39 | $1,972.10 | $2,296.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.79 / $1,089.58 / $2,185.08
| Professional | | $342.79 | $1,089.58 | $2,185.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.81 / $2,127.54 / $3,214.37
| Professional | | $1,694.81 | $2,127.54 | $3,214.37 |