- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.47 / $874.47 / $1,093.08
| Professional | | $874.47 | $874.47 | $1,093.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.97 / $1,421.97 / $1,421.97
| Facility | | $1,421.97 | $1,421.97 | $1,421.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.00 / $2,243.75 / $2,243.75
| Professional | | $734.00 | $2,243.75 | $2,243.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.55 / $623.66 / $798.04
| Facility | | $496.55 | $623.66 | $798.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.92 / $734.00 / $861.54
| Professional | | $526.92 | $734.00 | $861.54 |