- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.63 / $1,275.36 / $1,657.45
| Professional | | $1,154.63 | $1,275.36 | $1,657.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.37 / $260.37 / $260.37
| Facility | | $260.37 | $260.37 | $260.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.15 / $166.15 / $166.15
| Professional | | $166.15 | $166.15 | $166.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.14 / $1,516.14 / $2,075.01
| Facility | | $1,516.14 | $1,516.14 | $2,075.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.88 / $1,743.98 / $2,126.89
| Professional | | $169.88 | $1,743.98 | $2,126.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.20 / $1,057.80 / $2,021.34
| Professional | | $705.20 | $1,057.80 | $2,021.34 |