- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.31 / $2,226.61 / $2,226.61
| Professional | | $440.31 | $2,226.61 | $2,226.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.77 / $667.77 / $667.77
| Facility | | $667.77 | $667.77 | $667.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.03 / $667.77 / $702.47
| Professional | | $476.03 | $667.77 | $702.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.23 / $783.25 / $807.07
| Facility | | $330.23 | $783.25 | $807.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.82 / $601.29 / $867.30
| Professional | | $400.82 | $601.29 | $867.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.54 / $716.85 / $1,157.18
| Professional | | $614.54 | $716.85 | $1,157.18 |