- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.21 / $1,059.21 / $1,059.21
| Professional | | $1,059.21 | $1,059.21 | $1,059.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $561.79 / $936.32 / $970.52
| Facility | | $561.79 | $936.32 | $970.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.06 / $362.47 / $362.47
| Professional | | $300.06 | $362.47 | $362.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.00 / $2,031.53 / $2,242.96
| Facility | | $467.00 | $2,031.53 | $2,242.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,376.25 / $2,376.25 / $2,376.25
| Facility | | $2,376.25 | $2,376.25 | $2,376.25 |