- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.70 / $1,878.01 / $1,878.01
| Professional | | $411.70 | $1,878.01 | $1,878.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.63 / $593.63 / $593.63
| Facility | | $593.63 | $593.63 | $593.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.87 / $593.63 / $593.63
| Professional | | $467.87 | $593.63 | $593.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.25 / $366.56 / $593.63
| Facility | | $293.25 | $366.56 | $593.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.58 / $546.92 / $788.90
| Professional | | $364.58 | $546.92 | $788.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.00 / $651.62 / $1,039.69
| Professional | | $536.00 | $651.62 | $1,039.69 |