- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.38 / $2,727.52 / $2,727.52
| Professional | | $786.38 | $2,727.52 | $2,727.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.69 / $1,007.08 / $1,007.08
| Facility | | $510.69 | $1,007.08 | $1,007.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.69 / $1,007.08 / $1,007.08
| Professional | | $510.69 | $1,007.08 | $1,007.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.66 / $959.12 / $1,007.08
| Facility | | $455.66 | $959.12 | $1,007.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.69 / $755.85 / $1,007.80
| Professional | | $510.69 | $755.85 | $1,007.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.52 / $407.74 / $628.30
| Professional | | $368.52 | $407.74 | $628.30 |