- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.87 / $1,093.63 / $1,093.70
| Professional | | $815.87 | $1,093.63 | $1,093.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.90 / $1,033.06 / $1,033.06
| Professional | | $814.90 | $1,033.06 | $1,033.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $606.51
| Facility | | $606.51 | $606.51 | $606.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.53 / $606.51 / $606.51
| Professional | | $515.53 | $606.51 | $606.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.22 / $932.22 / $932.22
| Professional | | $932.22 | $932.22 | $932.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.95 / $697.80 / $1,009.33
| Professional | | $531.95 | $697.80 | $1,009.33 |