- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.41 / $2,844.97 / $2,844.97
| Professional | | $603.41 | $2,844.97 | $2,844.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.05 / $857.05 / $857.05
| Facility | | $857.05 | $857.05 | $857.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.75 / $857.05 / $930.62
| Professional | | $641.75 | $857.05 | $930.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.03 / $980.85 / $1,042.35
| Facility | | $422.03 | $980.85 | $1,042.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.86 / $779.88 / $1,124.90
| Professional | | $519.86 | $779.88 | $1,124.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.59 / $942.01 / $1,502.20
| Professional | | $769.59 | $942.01 | $1,502.20 |