- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.88 / $2,941.64 / $2,941.64
| Professional | | $511.88 | $2,941.64 | $2,941.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.18 / $941.18 / $941.18
| Facility | | $941.18 | $941.18 | $941.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.16 / $941.18 / $941.18
| Professional | | $611.16 | $941.18 | $941.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $459.20 / $933.57 / $941.18
| Facility | | $459.20 | $933.57 | $941.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.01 / $839.24 / $1,233.40
| Professional | | $570.01 | $839.24 | $1,233.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.26 / $961.65 / $1,648.35
| Professional | | $779.26 | $961.65 | $1,648.35 |