- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $1,119.45
| Professional | | $411.15 | $411.15 | $1,119.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.02 / $1,650.02 / $2,049.39
| Facility | | $1,650.02 | $1,650.02 | $2,049.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $1,246.74
| Professional | | $411.15 | $411.15 | $1,246.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $1,246.74
| Professional | | $411.15 | $411.15 | $1,246.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.08 / $427.26 / $1,209.24
| Professional | | $403.08 | $427.26 | $1,209.24 |