- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.27 / $944.27 / $1,180.33
| Professional | | $944.27 | $944.27 | $1,180.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.32 / $1,789.32 / $1,789.32
| Facility | | $1,789.32 | $1,789.32 | $1,789.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.00 / $3,807.00 / $3,807.00
| Professional | | $832.00 | $3,807.00 | $3,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.28 / $691.12 / $904.44
| Facility | | $533.28 | $691.12 | $904.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.28 / $893.36 / $948.29
| Professional | | $533.28 | $893.36 | $948.29 |