- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.62 / $1,020.62 / $1,275.78
| Professional | | $1,020.62 | $1,020.62 | $1,275.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,576.84 / $4,576.84 / $4,576.84
| Facility | | $4,576.84 | $4,576.84 | $4,576.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $4,363.00 / $4,363.00
| Professional | | $897.00 | $4,363.00 | $4,363.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.00 / $897.00 / $897.00
| Facility | | $897.00 | $897.00 | $897.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.00 / $975.44 / $1,008.00
| Professional | | $820.00 | $975.44 | $1,008.00 |