- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.06 / $1,567.38 / $2,037.03
| Professional | | $1,419.06 | $1,567.38 | $2,037.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.81 / $275.81 / $275.81
| Facility | | $275.81 | $275.81 | $275.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.21 / $204.21 / $204.21
| Professional | | $204.21 | $204.21 | $204.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $2,550.10
| Facility | | $1,450.41 | $1,450.41 | $2,550.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $1,450.41
| Professional | | $184.74 | $1,232.84 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.34 / $941.61 / $1,795.87
| Professional | | $733.34 | $941.61 | $1,795.87 |