- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.12 / $2,848.11 / $2,848.11
| Professional | | $575.12 | $2,848.11 | $2,848.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.93 / $874.93 / $874.93
| Facility | | $874.93 | $874.93 | $874.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.35 / $874.93 / $875.33
| Professional | | $600.35 | $874.93 | $875.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.47 / $951.60 / $1,103.71
| Facility | | $428.47 | $951.60 | $1,103.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.19 / $796.86 / $1,149.40
| Professional | | $531.19 | $796.86 | $1,149.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.64 / $936.96 / $1,529.04
| Professional | | $746.64 | $936.96 | $1,529.04 |