- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.66 / $985.00 / $3,698.80
| Professional | | $599.66 | $985.00 | $3,698.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.28 / $1,106.28 / $1,106.28
| Facility | | $1,106.28 | $1,106.28 | $1,106.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.00 / $1,106.28 / $1,181.46
| Professional | | $471.00 | $1,106.28 | $1,181.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.35 / $603.11 / $1,106.28
| Facility | | $483.35 | $603.11 | $1,106.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.08 / $1,106.28 / $1,449.00
| Professional | | $648.08 | $1,106.28 | $1,449.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.16 / $1,124.20 / $1,285.34
| Professional | | $953.16 | $1,124.20 | $1,285.34 |