- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.76 / $727.76 / $727.76
| Professional | | $727.76 | $727.76 | $727.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,968.81 / $3,968.81 / $3,968.81
| Facility | | $3,968.81 | $3,968.81 | $3,968.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.58 / $1,052.60 / $3,279.00
| Professional | | $922.58 | $1,052.60 | $3,279.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.58 / $1,052.60 / $3,279.00
| Professional | | $922.58 | $1,052.60 | $3,279.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.24 / $990.12 / $3,488.00
| Professional | | $673.24 | $990.12 | $3,488.00 |