- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.25 / $3,025.98 / $3,025.98
| Professional | | $413.25 | $3,025.98 | $3,025.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $695.41 / $1,140.65 / $1,140.65
| Facility | | $695.41 | $1,140.65 | $1,140.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.41 / $927.57 / $1,140.65
| Professional | | $695.41 | $927.57 | $1,140.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $535.17 / $1,086.33 / $1,140.65
| Facility | | $535.17 | $1,086.33 | $1,140.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.41 / $856.11 / $1,141.48
| Professional | | $695.41 | $856.11 | $1,141.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.83 / $478.89 / $732.83
| Professional | | $432.83 | $478.89 | $732.83 |