- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $2,137.96
| Professional | | $870.96 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $1,819.70
| Facility | | $54.95 | $56.23 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $1,230.27
| Facility | | $512.86 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $660.69 / $1,288.25
| Facility | | $524.81 | $660.69 | $1,288.25 |