- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.13 / $2,476.55 / $2,476.55
| Professional | | $593.13 | $2,476.55 | $2,476.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $744.53 / $744.53 / $744.53
| Facility | | $744.53 | $744.53 | $744.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.91 / $744.53 / $779.88
| Professional | | $520.91 | $744.53 | $779.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.71 / $868.40 / $895.62
| Facility | | $367.71 | $868.40 | $895.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.43 / $669.71 / $966.00
| Professional | | $446.43 | $669.71 | $966.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.36 / $810.60 / $1,288.53
| Professional | | $681.36 | $810.60 | $1,288.53 |