- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.30 / $1,553.18 / $1,716.60
| Professional | | $1,320.30 | $1,553.18 | $1,716.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.90 / $209.11 / $1,101.53
| Facility | | $169.90 | $209.11 | $1,101.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.90 / $182.97 / $1,186.26
| Professional | | $169.90 | $182.97 | $1,186.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $2,470.31
| Facility | | $1,450.41 | $1,450.41 | $2,470.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,450.41 / $10,330.61
| Professional | | $184.74 | $1,450.41 | $10,330.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.78 / $1,230.58 / $1,647.56
| Professional | | $834.78 | $1,230.58 | $1,647.56 |