- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $1,445.44
| Facility | | $812.83 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $812.83
| Professional | | $616.60 | $616.60 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $3,548.13
| Facility | | $1,318.26 | $1,548.82 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |