- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,288.25 / $1,862.09
| Professional | | $1,148.15 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $398.11
| Professional | | $338.84 | $338.84 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.79 / $707.95 / $1,348.96
| Facility | | $70.79 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,023.29 / $1,230.27
| Professional | | $645.65 | $1,023.29 | $1,230.27 |