- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.05 / $3,204.08 / $3,204.08
| Professional | | $683.05 | $3,204.08 | $3,204.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.40 / $935.40 / $935.40
| Facility | | $935.40 | $935.40 | $935.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.45 / $935.40 / $935.40
| Professional | | $810.45 | $935.40 | $935.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.40 / $935.40 / $935.40
| Facility | | $935.40 | $935.40 | $935.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.36 / $822.19 / $1,255.80
| Professional | | $580.36 | $822.19 | $1,255.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.96 / $1,097.40 / $1,648.35
| Professional | | $940.96 | $1,097.40 | $1,648.35 |