- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.02 / $1,402.28 / $1,551.90
| Professional | | $1,192.02 | $1,402.28 | $1,551.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.60 / $173.50 / $354.47
| Facility | | $153.60 | $173.50 | $354.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.60 / $165.42 / $212.68
| Professional | | $153.60 | $165.42 | $212.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,522.88
| Facility | | $1,639.62 | $1,639.62 | $2,522.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $10,550.45
| Professional | | $188.66 | $1,639.62 | $10,550.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.85 / $1,193.63 / $1,705.19
| Professional | | $937.85 | $1,193.63 | $1,705.19 |