- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.83 / $1,384.87 / $1,799.85
| Professional | | $1,253.83 | $1,384.87 | $1,799.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Facility | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.43 / $180.43 / $180.43
| Professional | | $180.43 | $180.43 | $180.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $2,253.16
| Facility | | $171.39 | $1,071.00 | $2,253.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $910.35 / $1,071.00
| Professional | | $163.22 | $910.35 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.02 / $1,065.34 / $1,891.91
| Professional | | $648.02 | $1,065.34 | $1,891.91 |