- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.63 / $1,856.30 / $2,412.52
| Professional | | $1,680.63 | $1,856.30 | $2,412.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.66 / $326.66 / $326.66
| Facility | | $326.66 | $326.66 | $326.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.85 / $241.85 / $241.85
| Professional | | $241.85 | $241.85 | $241.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,020.16
| Facility | | $1,406.76 | $1,406.76 | $3,020.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $1,406.76
| Professional | | $218.80 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,427.98 / $2,788.22
| Professional | | $868.60 | $1,427.98 | $2,788.22 |