- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.08 / $689.33 / $689.33
| Professional | | $622.08 | $689.33 | $689.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,723.81 / $1,946.10
| Facility | | $0.02 | $1,723.81 | $1,946.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,485.34 / $2,485.34 / $2,485.34
| Facility | | $2,485.34 | $2,485.34 | $2,485.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.01 / $966.01 / $1,207.51
| Professional | | $966.01 | $966.01 | $1,207.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.23 / $504.39 / $1,212.47
| Professional | | $294.23 | $504.39 | $1,212.47 |