- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.61 / $2,527.80 / $3,337.65
| Professional | | $503.61 | $2,527.80 | $3,337.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.71 / $727.71 / $727.71
| Facility | | $727.71 | $727.71 | $727.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.76 / $854.38 / $1,088.92
| Professional | | $658.76 | $854.38 | $1,088.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.29 / $1,049.09 / $1,160.01
| Facility | | $454.29 | $1,049.09 | $1,160.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.33 / $732.77 / $1,088.92
| Professional | | $476.33 | $732.77 | $1,088.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.07 / $1,049.09 / $1,692.76
| Professional | | $837.07 | $1,049.09 | $1,692.76 |