- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.04 / $3,394.20 / $3,394.20
| Professional | | $607.04 | $3,394.20 | $3,394.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.35 / $707.35 / $707.35
| Professional | | $707.35 | $707.35 | $707.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.41 / $897.38 / $3,008.86
| Facility | | $765.41 | $897.38 | $3,008.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.41 / $765.41 / $765.41
| Professional | | $765.41 | $765.41 | $765.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.41 / $897.38 / $3,008.86
| Facility | | $765.41 | $897.38 | $3,008.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.08 / $475.08 / $765.41
| Professional | | $475.08 | $475.08 | $765.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.71 / $221.71 / $527.87
| Professional | | $221.71 | $221.71 | $527.87 |