- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.06 / $1,076.73 / $1,369.53
| Professional | | $954.06 | $1,076.73 | $1,369.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.44 / $185.44 / $185.44
| Facility | | $185.44 | $185.44 | $185.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.30 / $137.30 / $137.30
| Professional | | $137.30 | $137.30 | $137.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.04 / $860.04 / $860.04
| Facility | | $860.04 | $860.04 | $860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.91 / $860.04 / $860.04
| Professional | | $126.91 | $860.04 | $860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.81 / $629.77 / $1,007.17
| Professional | | $503.81 | $629.77 | $1,007.17 |