- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.08 / $1,428.96 / $1,512.06
| Professional | | $1,247.08 | $1,428.96 | $1,512.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.87 / $355.22 / $410.75
| Facility | | $181.87 | $355.22 | $410.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.59 / $181.87 / $181.87
| Professional | | $154.59 | $181.87 | $181.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.98 / $2,837.98 / $2,837.98
| Professional | | $2,837.98 | $2,837.98 | $2,837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.58 / $1,796.62 / $2,995.70
| Professional | | $1,104.58 | $1,796.62 | $2,995.70 |