- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.21 / $2,564.15 / $2,564.15
| Professional | | $525.21 | $2,564.15 | $2,564.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.51 / $764.51 / $764.51
| Facility | | $764.51 | $764.51 | $764.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.48 / $764.51 / $764.51
| Professional | | $573.48 | $764.51 | $764.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.51 / $880.10 / $912.07
| Facility | | $764.51 | $880.10 | $912.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.37 / $650.79 / $994.00
| Professional | | $459.37 | $650.79 | $994.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.54 / $841.81 / $1,325.51
| Professional | | $690.54 | $841.81 | $1,325.51 |