- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.96 / $622.96 / $1,280.38
| Facility | | $622.96 | $622.96 | $1,280.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.96 / $657.14 / $1,424.00
| Professional | | $622.96 | $657.14 | $1,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.00 / $1,286.40 / $1,296.00
| Professional | | $1,088.00 | $1,286.40 | $1,296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $420.47 / $528.71
| Professional | | $416.30 | $420.47 | $528.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.96 / $622.96 / $1,059.03
| Facility | | $622.96 | $622.96 | $1,059.03 |