- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $2,843.00
| Professional | | $2,843.00 | $2,843.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.13 / $563.46 / $987.84
| Facility | | $368.13 | $563.46 | $987.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.28 / $770.69 / $770.69
| Professional | | $634.28 | $770.69 | $770.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.00 / $1,438.00 / $2,400.00
| Facility | | $133.00 | $1,438.00 | $2,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.00 / $1,727.00 / $2,883.00
| Facility | | $133.00 | $1,727.00 | $2,883.00 |