- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $2,344.23
| Professional | | $1,380.38 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $144.54
| Professional | | $123.03 | $123.03 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $758.58 / $1,412.54
| Facility | | $85.11 | $758.58 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $1,621.81
| Professional | | $851.14 | $1,348.96 | $1,621.81 |