- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $573.46 / $573.46
| Professional | | $573.46 | $573.46 | $573.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.36 / $28.96 / $39.71
| Facility | | $20.36 | $28.96 | $39.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.34 / $1,040.34 / $1,040.34
| Professional | | $1,040.34 | $1,040.34 | $1,040.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.46 / $573.46 / $766.50
| Facility | | $573.46 | $573.46 | $766.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.42 / $609.25 / $1,483.00
| Professional | | $423.42 | $609.25 | $1,483.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.12 / $992.12 / $1,063.10
| Professional | | $992.12 | $992.12 | $1,063.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.42 / $609.25 / $1,047.91
| Professional | | $423.42 | $609.25 | $1,047.91 |