- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $478.63 / $1,096.48
| Professional | | $407.38 | $478.63 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,570.40 / $2,570.40
| Facility | | $831.76 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,122.02
| Professional | | $501.19 | $501.19 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $501.19 / $1,148.15
| Professional | | $218.78 | $501.19 | $1,148.15 |