- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.64 / $2,036.72 / $2,036.72
| Professional | | $440.64 | $2,036.72 | $2,036.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.57 / $602.57 / $602.57
| Facility | | $602.57 | $602.57 | $602.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.57 / $602.57 / $742.19
| Professional | | $602.57 | $602.57 | $742.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.57 / $1,160.90 / $1,197.32
| Facility | | $602.57 | $1,160.90 | $1,197.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.70 / $556.70 / $804.30
| Professional | | $371.70 | $556.70 | $804.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.48 / $744.08 / $1,160.90
| Professional | | $610.48 | $744.08 | $1,160.90 |