- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.02 / $2,106.14 / $2,900.50
| Professional | | $347.02 | $2,106.14 | $2,900.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.74 / $585.74 / $585.74
| Facility | | $585.74 | $585.74 | $585.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.88 / $728.06 / $1,056.91
| Professional | | $497.88 | $728.06 | $1,056.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.34 / $473.53 / $946.40
| Facility | | $331.34 | $473.53 | $946.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.93 / $655.83 / $940.82
| Professional | | $462.93 | $655.83 | $940.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.91 / $905.66 / $992.20
| Professional | | $828.91 | $905.66 | $992.20 |