- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.23 / $1,791.78 / $2,328.69
| Professional | | $1,622.23 | $1,791.78 | $2,328.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.29 / $315.29 / $315.29
| Facility | | $315.29 | $315.29 | $315.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.44 / $233.44 / $233.44
| Professional | | $233.44 | $233.44 | $233.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $2,915.20
| Facility | | $1,219.64 | $1,219.64 | $2,915.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $1,219.64
| Professional | | $211.18 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.43 / $1,181.47 / $2,447.41
| Professional | | $838.43 | $1,181.47 | $2,447.41 |