- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.65 / $701.65 / $1,228.80
| Professional | | $701.65 | $701.65 | $1,228.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.40 / $1,370.40 / $1,370.40
| Professional | | $1,370.40 | $1,370.40 | $1,370.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,359.52
| Facility | | $606.51 | $606.51 | $1,359.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $606.51
| Professional | | $606.51 | $606.51 | $606.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.15 / $691.54 / $1,040.00
| Professional | | $585.15 | $691.54 | $1,040.00 |