- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.33 / $651.33 / $814.16
| Professional | | $651.33 | $651.33 | $814.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.24 / $658.25 / $13,311.95
| Facility | | $519.24 | $658.25 | $13,311.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.00 / $2,580.30 / $2,580.30
| Professional | | $573.00 | $2,580.30 | $2,580.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.00 / $573.00 / $573.00
| Facility | | $573.00 | $573.00 | $573.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $624.16 / $649.00
| Professional | | $525.00 | $624.16 | $649.00 |