- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.91 / $1,320.91 / $1,320.91
| Professional | | $1,320.91 | $1,320.91 | $1,320.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $144.19
| Facility | | $144.19 | $144.19 | $144.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.19 / $148.52 / $2,303.28
| Professional | | $144.19 | $148.52 | $2,303.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.66 / $231.14 / $1,843.17
| Facility | | $143.66 | $231.14 | $1,843.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.19 / $148.52 / $2,303.28
| Professional | | $144.19 | $148.52 | $2,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.19 / $835.19 / $1,237.98
| Professional | | $835.19 | $835.19 | $1,237.98 |