- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.52 / $1,051.90 / $2,048.44
| Professional | | $841.52 | $1,051.90 | $2,048.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $4,516.05
| Facility | | $55.00 | $55.00 | $4,516.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.44 / $2,109.44 / $2,109.44
| Professional | | $2,109.44 | $2,109.44 | $2,109.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.02 / $530.17 / $762.24
| Facility | | $438.02 | $530.17 | $762.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.80 / $475.80 / $475.80
| Professional | | $475.80 | $475.80 | $475.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.02 / $530.17 / $762.24
| Facility | | $438.02 | $530.17 | $762.24 |