- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,372.96 / $1,784.36
| Professional | | $645.61 | $1,372.96 | $1,784.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.59 / $241.59 / $241.59
| Facility | | $241.59 | $241.59 | $241.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.88 / $178.88 / $178.88
| Professional | | $178.88 | $178.88 | $178.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $2,233.78
| Facility | | $173.31 | $1,082.51 | $2,233.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $920.13 / $1,082.51
| Professional | | $161.82 | $920.13 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $824.84 / $1,875.53
| Professional | | $642.40 | $824.84 | $1,875.53 |