- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.19 / $3,136.55 / $3,136.55
| Professional | | $620.19 | $3,136.55 | $3,136.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.66 / $940.66 / $940.66
| Facility | | $940.66 | $940.66 | $940.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.70 / $940.66 / $1,059.24
| Professional | | $658.70 | $940.66 | $1,059.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.61 / $1,094.59 / $1,129.01
| Facility | | $465.61 | $1,094.59 | $1,129.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.51 / $846.85 / $1,221.50
| Professional | | $564.51 | $846.85 | $1,221.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.84 / $1,011.27 / $1,630.77
| Professional | | $858.84 | $1,011.27 | $1,630.77 |