- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,137.96
| Professional | | $1,778.28 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,096.48
| Facility | | $549.54 | $741.31 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,071.52
| Facility | | $524.81 | $758.58 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |