- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.01 / $3,062.66 / $3,062.66
| Professional | | $883.01 | $3,062.66 | $3,062.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.20 / $906.15 / $906.15
| Facility | | $582.20 | $906.15 | $906.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.20 / $736.89 / $906.15
| Professional | | $582.20 | $736.89 | $906.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.14 / $863.00 / $906.15
| Facility | | $481.14 | $863.00 | $906.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.20 / $680.10 / $906.80
| Professional | | $582.20 | $680.10 | $906.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.13 / $430.54 / $663.45
| Professional | | $389.13 | $430.54 | $663.45 |