- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.24 / $934.73 / $1,214.76
| Professional | | $846.24 | $934.73 | $1,214.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.47 / $164.47 / $164.47
| Facility | | $164.47 | $164.47 | $164.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.78 / $121.78 / $121.78
| Professional | | $121.78 | $121.78 | $121.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.03 / $511.03 / $511.03
| Facility | | $511.03 | $511.03 | $511.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $511.03 / $511.03
| Professional | | $125.89 | $511.03 | $511.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.49 / $660.61 / $1,651.53
| Professional | | $514.49 | $660.61 | $1,651.53 |