- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $598.36 / $733.22 / $2,434.36
| Facility | | $598.36 | $733.22 | $2,434.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.58 / $1,145.06 / $1,145.06
| Professional | | $1,033.58 | $1,145.06 | $1,145.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.35 / $1,648.48 / $3,094.62
| Facility | | $1,216.35 | $1,648.48 | $3,094.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.25 / $1,905.38 / $2,679.50
| Facility | | $679.25 | $1,905.38 | $2,679.50 |