- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.11 / $667.52 / $1,114.67
| Professional | | $422.11 | $667.52 | $1,114.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,860.91 / $2,860.91 / $3,663.98
| Facility | | $2,860.91 | $2,860.91 | $3,663.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.20 / $689.30 / $1,873.02
| Professional | | $436.20 | $689.30 | $1,873.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.63 / $939.45 / $1,873.02
| Professional | | $582.63 | $939.45 | $1,873.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.31 / $955.08 / $2,776.49
| Professional | | $716.31 | $955.08 | $2,776.49 |