- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.57 / $2,434.92 / $2,434.92
| Professional | | $1,461.57 | $2,434.92 | $2,434.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $919.66 / $919.66
| Facility | | $482.77 | $919.66 | $919.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.77 / $919.66 / $919.66
| Professional | | $482.77 | $919.66 | $919.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $875.87 / $919.66
| Facility | | $482.77 | $875.87 | $919.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.25 / $705.53 / $920.33
| Professional | | $690.25 | $705.53 | $920.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.22 / $385.44 / $611.30
| Professional | | $359.22 | $385.44 | $611.30 |