- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,698.24
| Facility | | $660.69 | $870.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $1,122.02
| Professional | | $371.54 | $562.34 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $912.01
| Facility | | $676.08 | $812.83 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,230.27
| Facility | | $426.58 | $724.44 | $1,230.27 |