- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.00 / $518.13 / $641.25
| Professional | | $513.00 | $518.13 | $641.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.20 / $830.78 / $1,909.65
| Facility | | $604.20 | $830.78 | $1,909.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.20 / $1,909.65 / $2,166.00
| Professional | | $604.20 | $1,909.65 | $2,166.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.20 / $714.70 / $1,057.34
| Facility | | $604.20 | $714.70 | $1,057.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.20 / $673.17 / $1,909.65
| Professional | | $604.20 | $673.17 | $1,909.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.50 / $1,595.17 / $1,798.62
| Professional | | $734.50 | $1,595.17 | $1,798.62 |