- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.58 / $1,222.42 / $1,534.28
| Professional | | $1,145.58 | $1,222.42 | $1,534.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.08 / $796.08 / $1,582.05
| Professional | | $796.08 | $796.08 | $1,582.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.08 / $936.57 / $1,582.05
| Professional | | $796.08 | $936.57 | $1,582.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.40 / $193.98 / $720.14
| Professional | | $53.40 | $193.98 | $720.14 |