- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,392.55 / $1,503.68
| Professional | | $1,263.08 | $1,392.55 | $1,503.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $173.31 / $1,082.51
| Facility | | $173.31 | $173.31 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.91 / $920.13 / $1,082.51
| Professional | | $169.91 | $920.13 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.79 / $1,602.79 / $1,602.79
| Professional | | $1,602.79 | $1,602.79 | $1,602.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.88 / $983.83 / $1,229.05
| Professional | | $655.88 | $983.83 | $1,229.05 |