- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,556.29 / $2,022.61
| Professional | | $731.78 | $1,556.29 | $2,022.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.86 / $273.86 / $273.86
| Facility | | $273.86 | $273.86 | $273.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.76 / $202.76 / $202.76
| Professional | | $202.76 | $202.76 | $202.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $2,532.06
| Facility | | $192.60 | $1,436.52 | $2,532.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,221.04 / $1,436.52
| Professional | | $183.43 | $1,221.04 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.29 / $935.12 / $2,125.83
| Professional | | $728.29 | $935.12 | $2,125.83 |