- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,238.72
| Professional | | $977.24 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $1,071.52 / $1,071.52
| Facility | | $169.82 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $1,071.52 / $1,096.48
| Professional | | $169.82 | $1,071.52 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $851.14 / $1,288.25
| Facility | | $114.82 | $851.14 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,737.80
| Professional | | $660.69 | $1,047.13 | $1,737.80 |