- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.13 / $1,531.97 / $2,080.19
| Professional | | $1,449.13 | $1,531.97 | $2,080.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.66 / $281.66 / $281.66
| Facility | | $281.66 | $281.66 | $281.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.54 / $208.54 / $208.54
| Professional | | $208.54 | $208.54 | $208.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,583.51
| Facility | | $1,639.62 | $1,639.62 | $2,583.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $1,639.62
| Professional | | $188.66 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.93 / $961.63 / $2,186.66
| Professional | | $748.93 | $961.63 | $2,186.66 |