- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.58 / $1,076.61 / $1,093.40
| Professional | | $860.58 | $1,076.61 | $1,093.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.67 / $1,464.54 / $1,464.54
| Professional | | $806.67 | $1,464.54 | $1,464.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.38 / $845.38 / $845.38
| Facility | | $845.38 | $845.38 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.57 / $718.57 / $845.38
| Professional | | $718.57 | $718.57 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.58 / $1,065.18 / $1,076.61
| Professional | | $860.58 | $1,065.18 | $1,076.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.17 / $89.71 / $1,063.48
| Professional | | $45.17 | $89.71 | $1,063.48 |