- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,096.48
| Professional | | $676.08 | $1,047.13 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $812.83 / $812.83
| Professional | | $93.33 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $1,202.26
| Professional | | $354.81 | $512.86 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $380.19 / $602.56
| Facility | | $57.54 | $380.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $1,202.26
| Professional | | $354.81 | $512.86 | $1,202.26 |