- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.85 / $1,267.72 / $1,267.72
| Professional | | $1,163.85 | $1,267.72 | $1,267.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.88 / $55.88 / $55.88
| Facility | | $55.88 | $55.88 | $55.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.75 / $1,354.64 / $2,491.55
| Professional | | $555.75 | $1,354.64 | $2,491.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.88 / $55.88 / $55.88
| Facility | | $55.88 | $55.88 | $55.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.75 / $1,354.64 / $2,491.55
| Professional | | $555.75 | $1,354.64 | $2,491.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.91 / $830.64 / $1,934.17
| Professional | | $616.91 | $830.64 | $1,934.17 |