- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,737.80
| Facility | | $933.25 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,258.93
| Professional | | $575.44 | $724.44 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,630.78 / $3,630.78
| Professional | | $891.25 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,890.45 / $3,890.45
| Facility | | $1,047.13 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,630.78 / $3,630.78
| Professional | | $1,778.28 | $3,630.78 | $3,630.78 |